Healthcare Provider Details

I. General information

NPI: 1801205646
Provider Name (Legal Business Name): LINDA LYLES NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 VETERANS PKWY S
MOULTRIE GA
31788-6705
US

IV. Provider business mailing address

1509 11TH ST SW
MOULTRIE GA
31768-5213
US

V. Phone/Fax

Practice location:
  • Phone: 229-873-6479
  • Fax: 229-890-6777
Mailing address:
  • Phone: 229-529-6029
  • Fax: 229-890-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN180751
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: