Provider Demographics
NPI:1568511756
Name:LYONS, CAROL ANN (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:LYONS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 TECUMSEH ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3720
Mailing Address - Country:US
Mailing Address - Phone:219-877-3203
Mailing Address - Fax:219-873-2388
Practice Address - Street 1:450 SAINT JOHN RD
Practice Address - Street 2:SUITE 550
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7354
Practice Address - Country:US
Practice Address - Phone:219-877-3203
Practice Address - Fax:219-873-2388
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28124750A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN485380Medicare ID - Type UnspecifiedSWANSON CENTER