Basic Information
| Provider Information | |||||||||
| NPI: | 1538162169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOCK | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | |||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972844 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | |||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | F420310-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 367A00000X | 000916 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | RN202416 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LW0102X | RN202416 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 152958666B | 05 | GA | MEDICAID | 02201430 | 05 | NY | MEDICAID |