Provider Demographics
NPI:1700046794
Name:LYNN, VICKI D (PTA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:D
Last Name:LYNN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:KY
Mailing Address - Zip Code:42064-1913
Mailing Address - Country:US
Mailing Address - Phone:270-969-0442
Mailing Address - Fax:
Practice Address - Street 1:202 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1913
Practice Address - Country:US
Practice Address - Phone:270-969-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02411225200000X
CA9688225200000X
PATEI002441225200000X
TX2079983225200000X
SC2403225200000X
VA2306602498225200000X
DC000001225200000X
MDA3353225200000X
IL005420225200000X
FL21997225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant