Basic Information
| Provider Information | |||||||||
| NPI: | 1063495158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIELLIN | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 208093 | ||||||||
| Address2: | 367 CEDAR STREET | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065208093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036889106 | ||||||||
| FaxNumber: | 2037373306 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 HOWARD AVE | ||||||||
| Address2: | YALE PHYSICIANS BUILDING | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036882471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 037691 | CT | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 001376913 | 05 | CT | MEDICAID |