Provider Demographics
NPI:1306450648
Name:LIN, CASSANDRA RAE (NP)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:RAE
Last Name:LIN
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 1:2705 GINGHAMSBURG FREDERICK RD
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-8992
Mailing Address - Country:US
Mailing Address - Phone:937-545-3690
Mailing Address - Fax:
Practice Address - Street 1:1010 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1400
Practice Address - Country:US
Practice Address - Phone:375-282-2889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1011495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX418375801Medicaid