Healthcare Provider Details

I. General information

NPI: 1659241578
Provider Name (Legal Business Name): ELIZABETH LYTTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 PREMIER DR
HIGH POINT NC
27265-8357
US

IV. Provider business mailing address

500 ASHBRY RUN
WINSTON SALEM NC
27106-9557
US

V. Phone/Fax

Practice location:
  • Phone: 336-802-2250
  • Fax:
Mailing address:
  • Phone: 336-682-5262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-5869
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: