Healthcare Provider Details

I. General information

NPI: 1174439046
Provider Name (Legal Business Name): LYLE MERSHON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 SAN MATEO BLVD NE APT A4
ALBUQUERQUE NM
87109-6222
US

IV. Provider business mailing address

5360 SAN MATEO BLVD NE APT A4
ALBUQUERQUE NM
87109-6222
US

V. Phone/Fax

Practice location:
  • Phone: 661-204-5159
  • Fax:
Mailing address:
  • Phone: 661-204-5159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0002X
TaxonomyHigh-Risk Obstetric Registered Nurse
License Number83699
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: