Provider Demographics
NPI:1508179037
Name:LYKINS, JILL R (CNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:LYKINS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1309
Mailing Address - Fax:937-522-8940
Practice Address - Street 1:29 KYLE DR
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:OH
Practice Address - Zip Code:45314-9580
Practice Address - Country:US
Practice Address - Phone:937-766-2611
Practice Address - Fax:937-766-2611
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11560-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211286Medicaid