Provider Demographics
NPI:1770065922
Name:PERRY, LYNISE (CNS)
Entity type:Individual
Prefix:
First Name:LYNISE
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 RIVER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-6233
Mailing Address - Country:US
Mailing Address - Phone:234-564-3726
Mailing Address - Fax:
Practice Address - Street 1:638 INDEPENDENCE PKWY
Practice Address - Street 2:STE 240
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5222
Practice Address - Country:US
Practice Address - Phone:234-564-3726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 133N00000X
MDDX4713133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education