Provider Demographics
NPI:1821498098
Name:LYNCH-PHELPS, MARVA DEANE
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:DEANE
Last Name:LYNCH-PHELPS
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:PO BOX 62707
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-2707
Mailing Address - Country:US
Mailing Address - Phone:239-938-9184
Mailing Address - Fax:239-313-4687
Practice Address - Street 1:13813 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4343
Practice Address - Country:US
Practice Address - Phone:239-936-1343
Practice Address - Fax:239-936-8507
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1345192363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0Q82OtherFL BLUE
FL014372900Medicaid
FL014372900Medicaid