Provider Demographics
NPI:1487811758
Name:DAHLSTROM, LYNNE (PTA)
Entity type:Individual
Prefix:MS
First Name:LYNNE
Middle Name:
Last Name:DAHLSTROM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S US HIGHWAY 1
Mailing Address - Street 2:APT. 706
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-5975
Mailing Address - Country:US
Mailing Address - Phone:561-301-2121
Mailing Address - Fax:
Practice Address - Street 1:717 S US HIGHWAY 1
Practice Address - Street 2:APT. 706
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-5975
Practice Address - Country:US
Practice Address - Phone:561-301-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA16736172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker