Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 10796 | TN |
NPI | 1336102912 |
---|---|
Provider Name | Dr. Kenny Wayne Lynn |
First Address | Cookeville, TN 38501-2419 |
Second Address | Cookeville, TN 38501-2419 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2006 |
Last Update Date | 30/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B03657 | (02) | TN |