MEDICARE: MABLE EULALEE LYONS

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	364SF0001X	Family Health Clinical Nurse Specialist	SP011007	PA
2	363LF0000X	Family Nurse Practitioner	SP011007	PA

General Provider Information

NPI Number	:	1508143421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MABLE EULALEE LYONS

Provider Business Mailing Address
First Line	:	PO BOX 746722
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6722
Country	:	US
Telephone Number	:	312-733-9730
Fax Number	:	773-866-8014

Provider Business Practice Location Address
First Line	:	2311 COTTMAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1007
Country	:	US
Telephone Number	:	215-444-7470
Fax Number	:

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

Provider Enumeration Date	:	11/06/2011
Last Update Date	:	04/30/2025

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