Provider Demographics
NPI:1770200065
Name:LYNCH, SHANNON (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 N PEREGRINE PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-1300
Mailing Address - Country:US
Mailing Address - Phone:208-866-6215
Mailing Address - Fax:
Practice Address - Street 1:2626 N PEREGRINE PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-1300
Practice Address - Country:US
Practice Address - Phone:208-866-6215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-39818163WL0100X
IDL-157021163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant