Provider Demographics
NPI:1518912369
Name:GAINES, LYZA TENNILLE (CRNP)
Entity Type:Individual
Prefix:
First Name:LYZA
Middle Name:TENNILLE
Last Name:GAINES
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL CENTER DR SW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-3421
Mailing Address - Country:US
Mailing Address - Phone:256-997-2820
Mailing Address - Fax:256-997-2890
Practice Address - Street 1:415 MEDICAL CENTER DR SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3421
Practice Address - Country:US
Practice Address - Phone:256-997-2820
Practice Address - Fax:256-997-2890
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-091459363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051533716Medicaid
AL515-33716OtherBCBS
AL515-33716OtherBCBS
AL051533716GAIMedicare PIN