Provider Demographics
NPI:1417639600
Name:GRIDER, LYNLY D
Entity Type:Individual
Prefix:MRS
First Name:LYNLY
Middle Name:D
Last Name:GRIDER
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 1:314 N JASPER WAY
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-2053
Mailing Address - Country:US
Mailing Address - Phone:405-990-5590
Mailing Address - Fax:
Practice Address - Street 1:3801 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1921
Practice Address - Country:US
Practice Address - Phone:918-268-7295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator