Healthcare Provider Details

I. General information

NPI: 1215980941
Provider Name (Legal Business Name): VALERIE B. LYON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 W RIVER WOODS PKWY SUITE 116
GLENDALE WI
53212-1080
US

IV. Provider business mailing address

788 N. JEFFERSON STREET SUITE 300 / ATTN. KAAREN BUTZEN
MILWAUKEE WI
53202-3710
US

V. Phone/Fax

Practice location:
  • Phone: 414-326-1563
  • Fax: 414-326-1589
Mailing address:
  • Phone: 414-272-8950
  • Fax: 414-272-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number40772
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number40772
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number40772
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: