Provider Demographics
NPI:1265835466
Name:LYON, KELLY (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LYON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 ETHAN WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2231
Mailing Address - Country:US
Mailing Address - Phone:916-482-4856
Mailing Address - Fax:
Practice Address - Street 1:1442 ETHAN WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2231
Practice Address - Country:US
Practice Address - Phone:916-482-4856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA835719163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory