Provider Demographics
NPI:1902090574
Name:LYNCH, BREANNA LYNN (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:LYNN
Last Name:LYNCH
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 US ROUTE 1
Mailing Address - Street 2:BUILDING C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7609
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:1577 CONGREES ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:201-662-1622
Practice Address - Fax:207-774-1814
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006281133V00000X
MEDI1048133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001783701Medicare PIN
ME001783702Medicare PIN