=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407340201
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TELISA LYONS-WASHINGTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2018
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1442 NW 206TH TER
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-318-3060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1442 NW 206TH TER
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-318-3060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number | 235111
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | 235111
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------