Provider Demographics
NPI:1104054519
Name:O'DONNELL, LYNN A (NP)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:A
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E GENESEE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1892
Mailing Address - Country:US
Mailing Address - Phone:315-471-1044
Mailing Address - Fax:315-474-4312
Practice Address - Street 1:1000 E GENESEE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1892
Practice Address - Country:US
Practice Address - Phone:315-471-1044
Practice Address - Fax:315-474-4312
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335960207QA0505X
NYF335960363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY335960OtherLICENSE
NY03121299Medicaid