Provider Demographics
NPI:1841381852
Name:DIDRIKSON, LYNNE M I (MD)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:M
Last Name:DIDRIKSON
Suffix:I
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 5TH ST SE
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723
Mailing Address - Country:US
Mailing Address - Phone:218-666-5941
Mailing Address - Fax:
Practice Address - Street 1:20 5TH ST SE
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-9702
Practice Address - Country:US
Practice Address - Phone:218-666-5941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine