Provider Demographics
NPI:1972837805
Name:LYNCH, NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1994 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6627
Mailing Address - Country:US
Mailing Address - Phone:910-254-9292
Mailing Address - Fax:910-254-9294
Practice Address - Street 1:1994 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6627
Practice Address - Country:US
Practice Address - Phone:910-254-9292
Practice Address - Fax:910-254-9294
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2177152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912915Medicaid
NC0930GOtherBCBS OF NC
NC0930GOtherBCBS OF NC
NC2484610AMedicare PIN