Provider Demographics
NPI:1417946146
Name:DAVIS, LYNN ANNETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:ANNETTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 GOLF COURSE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1729
Mailing Address - Country:US
Mailing Address - Phone:505-896-2010
Mailing Address - Fax:505-896-2012
Practice Address - Street 1:1721 GOLF COURSE RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1729
Practice Address - Country:US
Practice Address - Phone:505-896-2010
Practice Address - Fax:505-896-2012
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-15
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2400152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP1975Medicaid
NMU33447Medicare UPIN