MEDICARE: NICOLE LYSTNE M.A, M.S, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	26825	CA

General Provider Information

NPI Number	:	1225710957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LYSTNE M.A, M.S, CCC-SLP

Provider Business Mailing Address
First Line	:	3844 CANEHILL AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-2203
Country	:	US
Telephone Number	:	562-704-8851
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 AVIATION BLVD
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-4027
Country	:	US
Telephone Number	:	562-704-8851
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2023
Last Update Date	:	08/02/2023

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Directions to “ NICOLE LYSTNE M.A, M.S, CCC-SLP” Practice Location

Language	Start Address	Practice Location

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