Provider Demographics
NPI:1679571566
Name:GRYLLS, LYNN G (CNM)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:G
Last Name:GRYLLS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 N COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3895
Mailing Address - Country:US
Mailing Address - Phone:419-291-8541
Mailing Address - Fax:419-480-1340
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-8541
Practice Address - Fax:419-480-1340
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07382176B00000X
OHNM-07382367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4596910Medicaid
CA344428256OtherBEECH STREET
OH000000324462OtherANTHEM
344428256086OtherCARESOURCE
OH344428256OtherHEALTHNET
OH05225OtherPARAMOUNT
OH2461330Medicaid
OH000000324462OtherANTHEM
OH2461330Medicaid