Provider Demographics
NPI:1790029403
Name:LYNN, MICHELLE LEA (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEA
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 1:2050 WISE RD
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33540-7125
Mailing Address - Country:US
Mailing Address - Phone:727-433-2881
Mailing Address - Fax:
Practice Address - Street 1:4895 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-1316
Practice Address - Country:US
Practice Address - Phone:813-932-3315
Practice Address - Fax:813-935-9835
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 23645225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant