Healthcare Provider Details

I. General information

NPI: 1962437400
Provider Name (Legal Business Name): LYNN MARIE SQUANDA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNN MARIE SQUANDA DO

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 N STATE ST
SAINT IGNACE MI
49781-1048
US

IV. Provider business mailing address

524 S COURT AVE
GAYLORD MI
49735-1215
US

V. Phone/Fax

Practice location:
  • Phone: 906-643-8689
  • Fax: 906-643-4165
Mailing address:
  • Phone: 989-350-4105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013512
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: