Provider Demographics
NPI:1164175576
Name:LYNNE, ERICA (WSC, RN, PHD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:LYNNE
Suffix:
Gender:F
Credentials:WSC, RN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 GATOR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:FL
Mailing Address - Zip Code:33960-3312
Mailing Address - Country:US
Mailing Address - Phone:239-287-5341
Mailing Address - Fax:
Practice Address - Street 1:226 GATOR CREEK RD
Practice Address - Street 2:
Practice Address - City:VENUS
Practice Address - State:FL
Practice Address - Zip Code:33960-3312
Practice Address - Country:US
Practice Address - Phone:239-287-5341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004345600Medicaid
FL680101396Medicaid