Basic Information
| Provider Information | |||||||||
| NPI: | 1619457967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYNCH | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MADELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 FLORAL AVE | ||||||||
| Address2: | |||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117141220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169382501 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1530 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115542265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167588670 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2018 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.