Provider Demographics
NPI:1346203270
Name:OMALLEY, LYNN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:
Last Name:OMALLEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1727
Mailing Address - Country:US
Mailing Address - Phone:757-589-9981
Mailing Address - Fax:
Practice Address - Street 1:297 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 126
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2911
Practice Address - Country:US
Practice Address - Phone:757-385-0511
Practice Address - Fax:757-497-6201
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166859363LA2200X
NJNN067472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861562472Medicaid
NJNN067472OtherNP LICENSE