Provider Demographics
NPI:1245409713
Name:LEMON, MERRILL L
Entity Type:Individual
Prefix:
First Name:MERRILL
Middle Name:L
Last Name:LEMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SHELBY DR
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3435
Mailing Address - Country:US
Mailing Address - Phone:731-288-5056
Mailing Address - Fax:731-288-5067
Practice Address - Street 1:1400 SHELBY DR
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3435
Practice Address - Country:US
Practice Address - Phone:731-288-5056
Practice Address - Fax:731-288-5067
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000001167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4180906OtherBLUE CROSS BLUE SHIELD
TN1510384Medicaid