Provider Demographics
NPI:1174654651
Name:LYTLE, NICOLE ALICIA (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALICIA
Last Name:LYTLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ALICIA
Other - Last Name:TORAYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:503 SAINT MARLO DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028-8005
Mailing Address - Country:US
Mailing Address - Phone:478-953-1345
Mailing Address - Fax:
Practice Address - Street 1:116 S HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3904
Practice Address - Country:US
Practice Address - Phone:478-923-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003771363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical