Provider Demographics
NPI:1104946524
Name:LYNCH, CARLA JEAN
Entity type:Individual
Prefix:MS
First Name:CARLA
Middle Name:JEAN
Last Name:LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 NBU
Mailing Address - Street 2:1226 W 15TH ST
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-3520
Mailing Address - Country:US
Mailing Address - Phone:405-567-7568
Mailing Address - Fax:
Practice Address - Street 1:800 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-3732
Practice Address - Country:US
Practice Address - Phone:405-372-1250
Practice Address - Fax:405-377-5215
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator