Provider Demographics
NPI:1134179740
Name:LYNCH, KATHLEEN M (DPM)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:LYNCH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-637-5500
Mailing Address - Fax:315-637-5588
Practice Address - Street 1:512 TOWNE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1331
Practice Address - Country:US
Practice Address - Phone:315-637-5500
Practice Address - Fax:315-637-5588
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004991213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01680491Medicaid
DD5795Medicare ID - Type Unspecified
NY01680491Medicaid