Provider Demographics
NPI:1952448961
Name:PIERSON, LYNAE AILEEN (DPM)
Entity Type:Individual
Prefix:
First Name:LYNAE
Middle Name:AILEEN
Last Name:PIERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3832
Mailing Address - Country:US
Mailing Address - Phone:217-429-1512
Mailing Address - Fax:217-423-1465
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:STE 100
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3832
Practice Address - Country:US
Practice Address - Phone:217-429-1512
Practice Address - Fax:217-423-1465
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL016004984213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004984Medicaid
ILU80895Medicare UPIN
IL016004984Medicaid