Basic Information
| Provider Information | |||||||||
| NPI: | 1760467245 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089410838 | ||||||||
| FaxNumber: | 5089410893 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LIBERTY STREET | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 184553 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0102041 | 05 | MA | MEDICAID |