Healthcare Provider Details

I. General information

NPI: 1174654651
Provider Name (Legal Business Name): NICOLE ALICIA LYTLE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ALICIA TORAYA PA

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PRINCE AVE
ATHENS GA
30606-2797
US

IV. Provider business mailing address

503 SAINT MARLO DR
CENTERVILLE GA
31028-8005
US

V. Phone/Fax

Practice location:
  • Phone: 478-464-8134
  • Fax:
Mailing address:
  • Phone: 478-953-1345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3771
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3771
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: