Healthcare Provider Details

I. General information

NPI: 1184232936
Provider Name (Legal Business Name): KEONEE N LYLES LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

10187 CHAPARRAL WAY UNIT C
RANCHO CUCAMONGA CA
91730-3790
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax:
Mailing address:
  • Phone: 626-319-4189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number710726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: