=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538063094
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYSETTE NKONGYO APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2026
-----------------------------------------------------
Last Update Date | 10/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 276 DOWLER DR
-----------------------------------------------------
City | SOUTH BLOOMFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43103-9241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-661-1763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 276 DOWLER DR
-----------------------------------------------------
City | SOUTH BLOOMFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43103-9241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-661-1763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------