Healthcare Provider Details

I. General information

NPI: 1356092571
Provider Name (Legal Business Name): JOHN MARVIN LYTLE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 WESTLAND DR SW
CLEVELAND TN
37311-8163
US

IV. Provider business mailing address

5346 COLLEGEVIEW DR
OOLTEWAH TN
37363-8734
US

V. Phone/Fax

Practice location:
  • Phone: 423-478-1970
  • Fax:
Mailing address:
  • Phone: 772-349-1084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number30618
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: