Basic Information
| Provider Information | |||||||||
| NPI: | 1619961109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5750 W THUNDERBIRD RD | ||||||||
| Address2: | SUITE G 700 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853064660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028435455 | ||||||||
| FaxNumber: | 6028438426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN057432 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 577281 | 05 | AZ | MEDICAID |