Provider Demographics
NPI:1083613863
Name:RUPP, LYNN MARIE (PT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:RUPP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 STATE ST
Mailing Address - Street 2:SUITE 16, LL
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1341
Mailing Address - Country:US
Mailing Address - Phone:814-480-7100
Mailing Address - Fax:814-480-7604
Practice Address - Street 1:5100 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2482
Practice Address - Country:US
Practice Address - Phone:814-864-5097
Practice Address - Fax:814-864-9583
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008173L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00170285OtherRR MEDICARE
PA1008723830007Medicaid
PA001607036OtherBLUE SHIELD
PA146211OtherUNISON
PA251403958OtherUPMC
PA076460E7CMedicare PIN
PA251403958OtherUPMC