Provider Demographics
NPI:1356092571
Name:LYTLE, JOHN MARVIN JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARVIN
Last Name:LYTLE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5346 COLLEGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-8734
Mailing Address - Country:US
Mailing Address - Phone:772-349-1084
Mailing Address - Fax:
Practice Address - Street 1:2020 WESTLAND DR SW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-8163
Practice Address - Country:US
Practice Address - Phone:423-478-1970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30618363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health