Provider Demographics
NPI:1619674678
Name:LYLES-LEWIS, MARION MERICK
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:MERICK
Last Name:LYLES-LEWIS
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 1:634 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5247
Mailing Address - Country:US
Mailing Address - Phone:612-323-6045
Mailing Address - Fax:
Practice Address - Street 1:634 HIDDEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5247
Practice Address - Country:US
Practice Address - Phone:612-323-6045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN201103363LP0808X
TN2022141217363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty