Provider Demographics
NPI:1710972401
Name:TELCK, LYNNETTE C (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNNETTE
Middle Name:C
Last Name:TELCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:214 S. 4TH ST
Mailing Address - City:KREMMLING
Mailing Address - State:CO
Mailing Address - Zip Code:80459-0399
Mailing Address - Country:US
Mailing Address - Phone:970-724-3442
Mailing Address - Fax:970-724-9359
Practice Address - Street 1:214 SOUTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:KREMMLING
Practice Address - State:CO
Practice Address - Zip Code:80459-0399
Practice Address - Country:US
Practice Address - Phone:970-724-3442
Practice Address - Fax:970-724-9359
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1428543Medicaid
H89575Medicare UPIN
CO1428543Medicaid