Provider Demographics
NPI:1861215931
Name:DISTEFANO, LYNNE (PTA)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3303
Mailing Address - Country:US
Mailing Address - Phone:718-490-0594
Mailing Address - Fax:
Practice Address - Street 1:4363 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3819
Practice Address - Country:US
Practice Address - Phone:718-984-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005177225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant