Provider Demographics
NPI:1891243986
Name:THALL, LYNNE (APRN)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:THALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:
Other - Last Name:THALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:1241 OVERLOOK RD
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5343
Mailing Address - Country:US
Mailing Address - Phone:321-228-8033
Mailing Address - Fax:352-835-5450
Practice Address - Street 1:1241 OVERLOOK RD
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5343
Practice Address - Country:US
Practice Address - Phone:321-228-8033
Practice Address - Fax:352-835-5450
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9336466363LF0000X
TNAPN22377363LP2300X
FLAPRN9336466363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0244507143Medicaid