Provider Demographics
NPI:1679924146
Name:LYNN, SHANE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:LYNN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 ALTERNATE 19 N 403B
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-5915
Mailing Address - Country:US
Mailing Address - Phone:727-275-3601
Mailing Address - Fax:727-238-8137
Practice Address - Street 1:2710 PALM HARBOR BLVD # 403B
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-2666
Practice Address - Country:US
Practice Address - Phone:277-275-3601
Practice Address - Fax:727-238-8137
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129984363LP0808X
FLRN9398198363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7276414435OtherNEW GRADUATE