Healthcare Provider Details

I. General information

NPI: 1164814802
Provider Name (Legal Business Name): MISS ASHLEY MONET LYLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

923 SAINT JOHNS BLVD
LINCOLN PARK MI
48146-4234
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax:
Mailing address:
  • Phone: 313-549-4652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303001887
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: