Provider Demographics
NPI:1619961109
Name:CHURCH, LYNN M (NP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:CHURCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 E WARNER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3494
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:
Practice Address - Street 1:5750 W THUNDERBIRD RD
Practice Address - Street 2:SUITE G 700
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4660
Practice Address - Country:US
Practice Address - Phone:602-843-5455
Practice Address - Fax:602-843-8426
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRN057432363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ577281Medicaid
AZ577281Medicaid
AZ115916Medicare PIN
Z72969Medicare ID - Type Unspecified