Provider Demographics
NPI:1851634091
Name:TIMMERMAN, LYNLY ROSE
Entity type:Individual
Prefix:
First Name:LYNLY
Middle Name:ROSE
Last Name:TIMMERMAN
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:PO BOX 1242
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1242
Mailing Address - Country:US
Mailing Address - Phone:912-225-3769
Mailing Address - Fax:
Practice Address - Street 1:27 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5245
Practice Address - Country:US
Practice Address - Phone:912-225-3769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC14593101YP2500X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist