Provider Demographics
NPI:1417343930
Name:LYSICK, NICHOLE LYNN (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LYNN
Last Name:LYSICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:LYNN
Other - Last Name:FOUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 S 8TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2776
Mailing Address - Country:US
Mailing Address - Phone:724-463-0476
Mailing Address - Fax:
Practice Address - Street 1:15 S 8TH ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-463-0476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
PAOS019207208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program