Provider Demographics
NPI:1780790782
Name:GRISMORE, LYNN SOARES (NP)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:SOARES
Last Name:GRISMORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 WEST LN STE 260
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3377
Mailing Address - Country:US
Mailing Address - Phone:209-476-3409
Mailing Address - Fax:
Practice Address - Street 1:7373 WEST LN
Practice Address - Street 2:OB/GYN B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3377
Practice Address - Country:US
Practice Address - Phone:209-476-3409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5362363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health