Provider Demographics
NPI:1740604883
Name:LYNCH, JUDIN
Entity Type:Individual
Prefix:
First Name:JUDIN
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 KOALA COURT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043
Mailing Address - Country:US
Mailing Address - Phone:770-635-8042
Mailing Address - Fax:877-366-0737
Practice Address - Street 1:919 KOALA CT
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7699
Practice Address - Country:US
Practice Address - Phone:770-635-8042
Practice Address - Fax:877-366-0737
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26-4017146302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization