Provider Demographics
NPI:1336102912
Name:LYNN, KENNY WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNY
Middle Name:WAYNE
Last Name:LYNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2419
Mailing Address - Country:US
Mailing Address - Phone:931-528-7418
Mailing Address - Fax:931-525-6165
Practice Address - Street 1:210 W. CEDAR AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2419
Practice Address - Country:US
Practice Address - Phone:931-528-7418
Practice Address - Fax:931-525-6165
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10796204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB03657Medicare UPIN
TN3174362Medicare ID - Type Unspecified