Provider Demographics
NPI:1679280291
Name:LYTLE, ROBBIE SUE
Entity Type:Individual
Prefix:
First Name:ROBBIE
Middle Name:SUE
Last Name:LYTLE
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 1:2310 17TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-2014
Mailing Address - Country:US
Mailing Address - Phone:330-209-6888
Mailing Address - Fax:
Practice Address - Street 1:2310 17TH ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-2014
Practice Address - Country:US
Practice Address - Phone:330-209-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNONEMedicaid