Provider Demographics
NPI:1912306002
Name:BROEKER, LYNELLE (LMT)
Entity Type:Individual
Prefix:
First Name:LYNELLE
Middle Name:
Last Name:BROEKER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6984 ERRICK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-1145
Mailing Address - Country:US
Mailing Address - Phone:716-523-6605
Mailing Address - Fax:
Practice Address - Street 1:2728 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-4587
Practice Address - Country:US
Practice Address - Phone:716-523-6605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27027804225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist