Provider Demographics
NPI:1356087993
Name:MEDLEY, LYNETTE
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:MEDLEY
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 1:815 E LEE ST APT 7B
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2034
Mailing Address - Country:US
Mailing Address - Phone:133-444-9132
Mailing Address - Fax:
Practice Address - Street 1:1880 S UNION AVE C, OZARK, AL 36360
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360
Practice Address - Country:US
Practice Address - Phone:334-443-1043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21-193378106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5300012300198Medicaid