Provider Demographics
NPI:1548218142
Name:LYONS, COLLEEN (FNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:LYONS
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:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-0578
Mailing Address - Country:US
Mailing Address - Phone:803-433-6790
Mailing Address - Fax:803-433-6796
Practice Address - Street 1:12 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2925
Practice Address - Country:US
Practice Address - Phone:803-433-6790
Practice Address - Fax:803-433-6796
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5000023979Medicare ID - Type Unspecified
SCP540204397Medicare ID - Type Unspecified
SCP540204400Medicare ID - Type Unspecified
SCP540204399Medicare ID - Type Unspecified
SC54020Medicare UPIN
SCP540205009Medicare ID - Type Unspecified
SCP540204398Medicare ID - Type Unspecified