Provider Demographics
NPI:1639164247
Name:LYNN, STACIE R (OD)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:LYNN
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 SLOAN WAY
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-1205
Mailing Address - Country:US
Mailing Address - Phone:773-531-5568
Mailing Address - Fax:
Practice Address - Street 1:9863 BUSLETON AVE
Practice Address - Street 2:STE A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115
Practice Address - Country:US
Practice Address - Phone:215-969-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009376207W00000X
PAOEG002050152W00000X
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