Provider Demographics
NPI:1760787105
Name:STEVENS, LYN M
Entity Type:Individual
Prefix:MS
First Name:LYN
Middle Name:M
Last Name:STEVENS
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 1:395 SE PIUTE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-3935
Mailing Address - Country:US
Mailing Address - Phone:386-984-6759
Mailing Address - Fax:
Practice Address - Street 1:395 SE PIUTE WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-3935
Practice Address - Country:US
Practice Address - Phone:386-984-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-16
Last Update Date:2011-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL685257298 MCD172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685257298 MCDMedicaid