Healthcare Provider Details

I. General information

NPI: 1477337293
Provider Name (Legal Business Name): JESSICA LYONS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3283 FARTHING RD
ODIN IL
62870-2035
US

IV. Provider business mailing address

3283 FARTHING RD
ODIN IL
62870-2035
US

V. Phone/Fax

Practice location:
  • Phone: 618-780-1680
  • Fax:
Mailing address:
  • Phone: 618-780-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209019673
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: