Provider Demographics
NPI:1235650029
Name:JOSEPH, LYNN TATYANA (RN)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:TATYANA
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 MAGDALENE CT W
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-2982
Mailing Address - Country:US
Mailing Address - Phone:941-448-8105
Mailing Address - Fax:
Practice Address - Street 1:921 E PARKER ST STE 4
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-1901
Practice Address - Country:US
Practice Address - Phone:941-448-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019875400Medicaid