Provider Demographics
NPI:1831329416
Name:LYNCH, NIKKI DIANE (COTA)
Entity type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:DIANE
Last Name:LYNCH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 108
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-9538
Mailing Address - Country:US
Mailing Address - Phone:618-757-2267
Mailing Address - Fax:
Practice Address - Street 1:RR3 BOX 108
Practice Address - Street 2:
Practice Address - City:MCLEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859
Practice Address - Country:US
Practice Address - Phone:618-757-2267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003116224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant