Healthcare Provider Details

I. General information

NPI: 1982024154
Provider Name (Legal Business Name): LYNNETTE JO STILES RNC-IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 NORTH MAIN STREET
TUBA CITY AZ
86045-0600
US

IV. Provider business mailing address

PO BOX 600 PPS BUSINESS OFFICE
TUBA CITY AZ
86045-0600
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2501
  • Fax: 928-283-2677
Mailing address:
  • Phone: 928-283-2781
  • Fax: 928-283-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number165443-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number03-666262
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number608203
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9220737
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0028762
License Number StateVT
# 6
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License NumberR92090-2
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number14957 IBCLC
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License NumberSTI104300163
License Number StateAR
# 9
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number196-13641
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: