Healthcare Provider Details

I. General information

NPI: 1750780698
Provider Name (Legal Business Name): LYNN GRUNKEMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2014
Last Update Date: 08/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

1280 W 90TH AVE APT 206
MERRILLVILLE IN
46410-6738
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1600
  • Fax:
Mailing address:
  • Phone: 937-673-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002293A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: