Provider Demographics
NPI:1295779171
Name:LYNCH, MONICA L (APN)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:L
Last Name:LYNCH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MISS
Other - First Name:MONICA
Other - Middle Name:L
Other - Last Name:KRUCHTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:5015 WIL ACRE DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3623
Mailing Address - Country:US
Mailing Address - Phone:815-708-0515
Mailing Address - Fax:815-708-0515
Practice Address - Street 1:2801 S SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-4205
Practice Address - Country:US
Practice Address - Phone:815-721-8288
Practice Address - Fax:815-721-8270
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005770363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
K27042Medicare UPIN