Provider Demographics
NPI:1295110310
Name:LYNCH, KELLY GROMMERSCH (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:GROMMERSCH
Last Name:LYNCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NORTHSIDE HOSPITAL - MANAGED CARE DEPARTMENT
Mailing Address - Street 2:1000 JOHNSON FERRY RD NE ATLANTA
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3034
Mailing Address - Country:US
Mailing Address - Phone:404-851-8097
Mailing Address - Fax:404-250-8010
Practice Address - Street 1:3400C OLD MILTON PKWY STE 290
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4438
Practice Address - Country:US
Practice Address - Phone:770-667-4343
Practice Address - Fax:770-772-0937
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19544363L00000X, 363LF0000X
GARN208756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3344Medicaid
SCSC65507126Medicare PIN