Provider Demographics
NPI:1639164247
Name:LYNN, STACIE R (OD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:LYNN
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 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3849
Mailing Address - Country:US
Mailing Address - Phone:773-772-2424
Mailing Address - Fax:773-772-2828
Practice Address - Street 1:1515 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-8566
Practice Address - Country:US
Practice Address - Phone:773-772-2424
Practice Address - Fax:773-772-2828
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009376207W00000X
IL046-009376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009376Medicaid
ILL86653Medicare ID - Type Unspecified
ILK18595Medicare PIN
IL046009376Medicaid