Provider Demographics
NPI:1497299945
Name:LYLE, STEPHANIE (FNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LYLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 METRO PL S STE 100
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5353
Mailing Address - Country:US
Mailing Address - Phone:630-345-2943
Mailing Address - Fax:
Practice Address - Street 1:3379 MAIN ST
Practice Address - Street 2:
Practice Address - City:MINERAL RIDGE
Practice Address - State:OH
Practice Address - Zip Code:44440-8800
Practice Address - Country:US
Practice Address - Phone:330-222-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005570363LF0000X
OH0027457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1497299945Medicaid