Healthcare Provider Details

I. General information

NPI: 1275260606
Provider Name (Legal Business Name): CASEY R LYLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N MONTE VISTA ST
ADA OK
74820-4613
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-5111
  • Fax: 580-436-1159
Mailing address:
  • Phone: 580-925-3286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: