Provider Demographics
NPI:1316335904
Name:FISHER, LYNELL BROOKE (PTA)
Entity type:Individual
Prefix:MISS
First Name:LYNELL
Middle Name:BROOKE
Last Name:FISHER
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 1:8764 WINDINGWOOD TRL NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-8080
Mailing Address - Country:US
Mailing Address - Phone:910-840-0819
Mailing Address - Fax:
Practice Address - Street 1:1011 PORTERS NECK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9196
Practice Address - Country:US
Practice Address - Phone:910-686-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5397225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant