Provider Demographics
NPI:1962469064
Name:O'DONNELL, LYNN M (PT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SOUTHPARK BLVD
Mailing Address - Street 2:SUITE B201
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5191
Mailing Address - Country:US
Mailing Address - Phone:904-824-1636
Mailing Address - Fax:904-824-7488
Practice Address - Street 1:105 SOUTHPARK BLVD
Practice Address - Street 2:SUITE B201
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5191
Practice Address - Country:US
Practice Address - Phone:904-824-1636
Practice Address - Fax:904-824-7488
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT4350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ81OtherBCBS
FLQ81OtherBCBS