Provider Demographics
NPI:1669450854
Name:LYONS, GLYNNIS J (DO)
Entity Type:Individual
Prefix:
First Name:GLYNNIS
Middle Name:J
Last Name:LYONS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 CORPORATE CIR STE 300
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7760
Mailing Address - Country:US
Mailing Address - Phone:702-910-3950
Mailing Address - Fax:
Practice Address - Street 1:13501 ICOT BLVD STE 114
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3729
Practice Address - Country:US
Practice Address - Phone:727-754-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS4419OtherFL AGENCY FOR HEALTH CARE ADMINISTRATION
FL82449Medicare PIN