Provider Demographics
NPI:1174741912
Name:COLVILLE, LYNNE L (APRN)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:L
Last Name:COLVILLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 ROUTE 30 N
Mailing Address - Street 2:
Mailing Address - City:BOMOSEEN
Mailing Address - State:VT
Mailing Address - Zip Code:05732-9647
Mailing Address - Country:US
Mailing Address - Phone:802-468-5641
Mailing Address - Fax:802-468-2923
Practice Address - Street 1:275 ROUTE 30 N
Practice Address - Street 2:
Practice Address - City:BOMOSEEN
Practice Address - State:VT
Practice Address - Zip Code:05732-9647
Practice Address - Country:US
Practice Address - Phone:802-468-5641
Practice Address - Fax:802-468-2923
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0011925363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0NS2006Medicaid
VT0NS2006Medicaid
NS200601Medicare PIN
VTNS2006Medicare ID - Type Unspecified