Provider Demographics
NPI:1700317583
Name:LYNN, KIERSTEN (PT)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:LYNN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 N BROWN RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8853
Mailing Address - Country:US
Mailing Address - Phone:575-208-8575
Mailing Address - Fax:505-349-0337
Practice Address - Street 1:1717 W 2ND ST STE 101
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-2027
Practice Address - Country:US
Practice Address - Phone:505-349-0332
Practice Address - Fax:505-349-0337
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4708208100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation