Healthcare Provider Details

I. General information

NPI: 1346810793
Provider Name (Legal Business Name): VI LY DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N WOLFE ST
BALTIMORE MD
21205-2110
US

IV. Provider business mailing address

4983 GRAND AVE
MONTCLAIR CA
91763-6433
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-4766
  • Fax:
Mailing address:
  • Phone: 909-630-8038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR242988
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95002110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: