Provider Demographics
NPI:1073127676
Name:LYNN, GLORIA IMMANUELLE
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:IMMANUELLE
Last Name:LYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5754 THORTON ST APT 203
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-7196
Mailing Address - Country:US
Mailing Address - Phone:812-568-1774
Mailing Address - Fax:
Practice Address - Street 1:2540 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1990
Practice Address - Country:US
Practice Address - Phone:614-470-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator