Provider Demographics
NPI:1902024672
Name:JENNINGS, LYNNE MICHELLE (RPA)
Entity Type:Individual
Prefix:MS
First Name:LYNNE
Middle Name:MICHELLE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:MRS
Other - First Name:LYNNE
Other - Middle Name:M
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA
Mailing Address - Street 1:4 SHIRLEY LN
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6809
Mailing Address - Country:US
Mailing Address - Phone:631-383-5226
Mailing Address - Fax:
Practice Address - Street 1:97 AMITY STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6004
Practice Address - Country:US
Practice Address - Phone:718-780-1647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003146-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant