Provider Demographics
NPI:1376057216
Name:BALENTINE, LYNNETTE FAE (NMD)
Entity type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:FAE
Last Name:BALENTINE
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1758 S BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-8616
Mailing Address - Country:US
Mailing Address - Phone:480-622-3035
Mailing Address - Fax:
Practice Address - Street 1:1855 S COUNTRY CLUB DR STE 111
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6124
Practice Address - Country:US
Practice Address - Phone:480-622-3035
Practice Address - Fax:480-622-3035
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14-1438175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath