Basic Information
| Provider Information | |||||||||
| NPI: | 1164543617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYNNE | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | SUITE N-1200 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693416261 | ||||||||
| FaxNumber: | 2693416261 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | SUITE N-1200 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417979 | ||||||||
| FaxNumber: | 2693416261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 05/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704159305 | MI | N | Nursing Service Providers | Registered Nurse | 367A00000X | 4704159305 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1164543617 | 05 | MI | MEDICAID | 1013089820 | 01 | MI | BCBSM - BWS | OTHER |