Provider Demographics
NPI:1184353518
Name:LYNN, STACIE LYN (ABOC, NCLEC, LDO)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LYN
Last Name:LYNN
Suffix:
Gender:F
Credentials:ABOC, NCLEC, LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-2194
Mailing Address - Country:US
Mailing Address - Phone:859-734-7139
Mailing Address - Fax:859-734-7453
Practice Address - Street 1:591 JOSEPH DR
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-2194
Practice Address - Country:US
Practice Address - Phone:859-734-7139
Practice Address - Fax:859-734-7453
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111622156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician