Provider Demographics
NPI:1265891345
Name:VAIL, LYNETTE (MT)
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:VAIL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18270 MARSHA ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7474
Mailing Address - Country:US
Mailing Address - Phone:734-925-6115
Mailing Address - Fax:
Practice Address - Street 1:14460 KING RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7939
Practice Address - Country:US
Practice Address - Phone:734-925-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000496225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist