Provider Demographics
NPI:1174532170
Name:WISNIEWSKI, LYNN MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:LYNN
Middle Name:MARIE
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 OTROBANDO AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360
Mailing Address - Country:US
Mailing Address - Phone:860-889-1948
Mailing Address - Fax:860-889-1101
Practice Address - Street 1:1666 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-464-1949
Practice Address - Fax:860-464-3118
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080004210CT01OtherBCBS
CT080004210CT022OtherANTHEM BCBS
CT080004210CT23OtherANTHEM BCBS
CT080004210CT024OtherANTHEM BCBS
CT080004210CT02OtherANTHEM BCBS