Provider Demographics
NPI:1265556245
Name:LYNN, RACHAEL DIANE (PT)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:DIANE
Last Name:LYNN
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 1:13537 BARRETT PARKWAY DRIVE
Mailing Address - Street 2:STE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5866
Mailing Address - Country:US
Mailing Address - Phone:314-821-9126
Mailing Address - Fax:314-821-9142
Practice Address - Street 1:1047 CENTURY DRIVE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3772
Practice Address - Country:US
Practice Address - Phone:618-307-3434
Practice Address - Fax:618-307-3435
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1170141225100000X
IL70015156225100000X
NE2535225100000X
MO2005010782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL53240003Medicare PIN
MO150900014Medicare PIN
MO151100014Medicare PIN