Provider Demographics
NPI:1992885974
Name:MATERNA, LYNANN MARIE
Entity type:Individual
Prefix:MRS
First Name:LYNANN
Middle Name:MARIE
Last Name:MATERNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYN
Other - Middle Name:MARIE
Other - Last Name:MATERNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4168 E BABBLING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6634
Mailing Address - Country:US
Mailing Address - Phone:520-320-7698
Mailing Address - Fax:
Practice Address - Street 1:1450 W PRINCE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3014
Practice Address - Country:US
Practice Address - Phone:520-696-8856
Practice Address - Fax:520-690-2405
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL1364235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ567414Medicaid