Healthcare Provider Details

I. General information

NPI: 1891072344
Provider Name (Legal Business Name): VIRGINA ALLEN LYTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 11/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9221 LANSBROOK LN
OKLAHOMA CITY OK
73132-2220
US

IV. Provider business mailing address

9221 LANSBROOK LN
OKLAHOMA CITY OK
73132-2220
US

V. Phone/Fax

Practice location:
  • Phone: 405-720-0851
  • Fax:
Mailing address:
  • Phone: 405-720-0851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberK081062161
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: