Healthcare Provider Details

I. General information

NPI: 1164719738
Provider Name (Legal Business Name): LISA B LYELL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 04/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

2401 W MAIN ST
MARION IL
62959-1188
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax: 618-998-5668
Mailing address:
  • Phone: 618-997-5311
  • Fax: 618-998-5668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209-008558
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: