Provider Demographics
NPI:1043462690
Name:LYON, SUSAN LYNETTE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNETTE
Last Name:LYON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:
Other - Last Name:LYON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:10440 BLACK MOUNTAIN RD.
Mailing Address - Street 2:SAN DIEGO MIRAMAR COLLEGE, STUDENT HEALTH SERVICES S103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126
Mailing Address - Country:US
Mailing Address - Phone:858-536-7881
Mailing Address - Fax:858-689-0387
Practice Address - Street 1:10440 BLACK MOUNTAIN RD
Practice Address - Street 2:SAN DIEGO MIRAMAR COLLEGE STUDENT HEALTH SERVICES S-103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126
Practice Address - Country:US
Practice Address - Phone:858-536-7881
Practice Address - Fax:858-689-0387
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11463363L00000X
CA403159163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse