Healthcare Provider Details

I. General information

NPI: 1063939304
Provider Name (Legal Business Name): MICHAEL ANDREW LYZNICKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N JOHN R WOODEN DR
WEST LAFAYETTE IN
47907-2117
US

IV. Provider business mailing address

2149 BRINDLEWOOD DR
PLAINFIELD IL
60586-7221
US

V. Phone/Fax

Practice location:
  • Phone: 765-494-3245
  • Fax:
Mailing address:
  • Phone: 815-302-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: