Provider Demographics
NPI:1366403107
Name:FAIRCHILD, LYNN (PA)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:MICHELLE
Other - Last Name:FAIRCHILD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:47 JOLLEY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3092
Mailing Address - Country:US
Mailing Address - Phone:860-243-3020
Mailing Address - Fax:860-243-3002
Practice Address - Street 1:47 JOLLEY DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3092
Practice Address - Country:US
Practice Address - Phone:860-243-3020
Practice Address - Fax:860-243-3002
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q58579Medicare UPIN
CT970001992Medicare PIN