Provider Demographics
NPI:1821321654
Name:SOPER, LYNN ELLEN (OTR)
Entity Type:Individual
Prefix:MISS
First Name:LYNN
Middle Name:ELLEN
Last Name:SOPER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12054 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9344
Mailing Address - Country:US
Mailing Address - Phone:616-850-3953
Mailing Address - Fax:
Practice Address - Street 1:900 S BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2146
Practice Address - Country:US
Practice Address - Phone:616-846-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004517174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist