MEDICARE: KELLY LYON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL3496	FL

General Provider Information

NPI Number	:	1811439037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LYON

Provider Business Mailing Address
First Line	:	15618 CHARTER OAKS TRL
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-8918
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 BEAR CROSSING DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-6004
Country	:	US
Telephone Number	:	904-686-4237
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2016
Last Update Date	:	11/07/2016

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Directions to “ KELLY LYON ” Practice Location

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