Provider Demographics
NPI:1780168096
Name:LYNCH, SHANNON
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10370 NE 97TH PL
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618-7298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 SW MCFARLANE AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5614
Practice Address - Country:US
Practice Address - Phone:386-758-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28533225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant