1659367498 NPI number — DR. LYNN ELLEN ENGLE-LANEVE O.D.

Table of content: DR. LYNN ELLEN ENGLE-LANEVE O.D. (NPI 1659367498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659367498 NPI number — DR. LYNN ELLEN ENGLE-LANEVE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENGLE-LANEVE
Provider First Name:
LYNN
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ENGLE
Provider Other First Name:
LYNN
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1659367498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
172 MAJESTIC PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKVIEW
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25071-9790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-965-6195
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 GREENBRIER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25311-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-342-5900
Provider Business Practice Location Address Fax Number:
304-342-6257
Provider Enumeration Date:
09/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  985-OD , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 985-OD , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WP0200X , with the licence number: 985-OD , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: 985-OD , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3101004000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".