Provider Demographics
NPI:1578681193
Name:LYALL, TARA NICHOLE
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:NICHOLE
Last Name:LYALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 BROWN CIR
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-6516
Mailing Address - Country:US
Mailing Address - Phone:423-323-4109
Mailing Address - Fax:
Practice Address - Street 1:1880 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-5190
Practice Address - Country:US
Practice Address - Phone:423-378-7311
Practice Address - Fax:423-378-7320
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000016072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist