Provider Demographics
NPI:1962166231
Name:LYNAM, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:LYNAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 N MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2318
Mailing Address - Country:US
Mailing Address - Phone:201-218-7777
Mailing Address - Fax:
Practice Address - Street 1:42 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2318
Practice Address - Country:US
Practice Address - Phone:201-218-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-23
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01198900363LF0000X, 363LF0000X
NJ26NR16248300363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7706901Medicaid