Provider Demographics
NPI:1164543617
Name:LYNNE, SANDRA LYNN (RN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:LYNNE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE N-1200
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-6261
Mailing Address - Fax:269-341-6261
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE N-1200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-7979
Practice Address - Fax:269-341-6261
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2014-05-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704159305163W00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164543617Medicaid
MI1013089820OtherBCBSM - BWS
MI1013089820OtherBCBSM - BWS