Provider Demographics
NPI:1811982853
Name:BROOKING, LYNN MARIE (MNT)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:BROOKING
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:MARIE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421
Mailing Address - Country:US
Mailing Address - Phone:812-275-1200
Mailing Address - Fax:812-275-1370
Practice Address - Street 1:2900 W 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421
Practice Address - Country:US
Practice Address - Phone:812-275-1200
Practice Address - Fax:812-275-1370
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN132700000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ50107Medicare UPIN
IN940070E5Medicare ID - Type Unspecified