Provider Demographics
NPI:1295163277
Name:LYNCH, MELISSA B
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 KERON WAY
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-4342
Mailing Address - Country:US
Mailing Address - Phone:706-339-3372
Mailing Address - Fax:
Practice Address - Street 1:1523 KERON WAY
Practice Address - Street 2:
Practice Address - City:GRACEWOOD
Practice Address - State:GA
Practice Address - Zip Code:30812
Practice Address - Country:US
Practice Address - Phone:706-339-3372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA462131890171W00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant