Healthcare Provider Details

I. General information

NPI: 1922647577
Provider Name (Legal Business Name): LISA LYLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 HAWTHORNE CIR
MADISON GA
30650-5099
US

IV. Provider business mailing address

1251 HAWTHORNE CIR
MADISON GA
30650-5099
US

V. Phone/Fax

Practice location:
  • Phone: 256-453-9070
  • Fax:
Mailing address:
  • Phone: 256-453-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: