Provider Demographics
NPI:1639714579
Name:LYLES, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LYLES
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 1:2 GREENLEAF CIR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NH
Mailing Address - Zip Code:03833-6429
Mailing Address - Country:US
Mailing Address - Phone:603-686-4987
Mailing Address - Fax:
Practice Address - Street 1:2 GREENLEAF CIR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NH
Practice Address - Zip Code:03833-6429
Practice Address - Country:US
Practice Address - Phone:603-686-4987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH074710-23363LP0808X
NH074710-21163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH2020000589OtherANCC