Provider Demographics
NPI:1154775393
Name:WOTELL, LYNN (RPH)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:WOTELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 MAIN ST NW
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2303
Mailing Address - Country:US
Mailing Address - Phone:815-929-0590
Mailing Address - Fax:815-929-1433
Practice Address - Street 1:655 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2303
Practice Address - Country:US
Practice Address - Phone:815-929-0590
Practice Address - Fax:815-929-1433
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-040859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist