Provider Demographics
NPI:1447398045
Name:LYTLE, ELSIE M
Entity Type:Individual
Prefix:MS
First Name:ELSIE
Middle Name:M
Last Name:LYTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELSIE
Other - Middle Name:M
Other - Last Name:JOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCO
Mailing Address - Street 1:4606 S GARNETT RD
Mailing Address - Street 2:#302
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5231
Mailing Address - Country:US
Mailing Address - Phone:918-664-6544
Mailing Address - Fax:918-664-0668
Practice Address - Street 1:4606 S GARNETT RD
Practice Address - Street 2:#302
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5231
Practice Address - Country:US
Practice Address - Phone:918-664-6544
Practice Address - Fax:918-664-0668
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNONE REQUIRED174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100810010-AMedicaid
KS200302570AOtherKANSAS MEDICAL ASSOC MCD
AR123441716OtherARK MEDICAID
OK731385829OtherTRICARE
OK0259450001OtherRR MEDICARE
MO323088005OtherMISSOURI MEDICAID
MO323088005OtherMISSOURI MEDICAID
OK0259450001Medicare Oscar/Certification