Provider Demographics
NPI:1952502163
Name:KIDDER, LYNN L (MPH, RD, CD, ATC)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:L
Last Name:KIDDER
Suffix:
Gender:F
Credentials:MPH, RD, CD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12052 WILMINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-6018
Mailing Address - Country:US
Mailing Address - Phone:206-280-3367
Mailing Address - Fax:
Practice Address - Street 1:12052 WILMINGTON WAY
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-6018
Practice Address - Country:US
Practice Address - Phone:206-280-3367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2255A2300XOtherATHLETIC TRAINER