Healthcare Provider Details

I. General information

NPI: 1891059622
Provider Name (Legal Business Name): MISTY DAWN LYTLE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9411 N LAMAR BLVD STE 120
AUSTIN TX
78753-4179
US

IV. Provider business mailing address

9411 N LAMAR BLVD STE 120
AUSTIN TX
78753-4179
US

V. Phone/Fax

Practice location:
  • Phone: 512-744-6000
  • Fax:
Mailing address:
  • Phone: 512-583-9679
  • Fax: 512-233-0985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number670751
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP121315
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: