Provider Demographics
NPI:1649630617
Name:MAIN, SIERRA LYN
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:LYN
Last Name:MAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIERRA
Other - Middle Name:LYN
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4606 NE BELL AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-7321
Mailing Address - Country:US
Mailing Address - Phone:580-919-8293
Mailing Address - Fax:
Practice Address - Street 1:4606 NE BELL AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-7321
Practice Address - Country:US
Practice Address - Phone:580-919-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator