Provider Demographics
NPI:1457337404
Name:MITCHELL, LYNN D (NP)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:D
Last Name:MITCHELL
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 1:629 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2842
Mailing Address - Country:US
Mailing Address - Phone:631-727-8217
Mailing Address - Fax:631-727-8101
Practice Address - Street 1:629 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2842
Practice Address - Country:US
Practice Address - Phone:631-727-8217
Practice Address - Fax:631-727-8101
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400846364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02585573Medicaid
NYQ51017Medicare UPIN
NY1224G1Medicare ID - Type Unspecified