Provider Demographics
NPI:1669437935
Name:LYNCH, LISA ANN (NPP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:LYNCH
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:LYNCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1526 WALDEN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4985
Mailing Address - Country:US
Mailing Address - Phone:716-895-7167
Mailing Address - Fax:716-896-0318
Practice Address - Street 1:1526 WALDEN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4985
Practice Address - Country:US
Practice Address - Phone:716-895-7167
Practice Address - Fax:716-896-0318
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380479363L00000X
NY401469363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
080129000134OtherFIDELIS
080407000099OtherFIDELIS