Provider Demographics
NPI:1689096547
Name:LYONS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LYONS
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 1:26 FIREMANS MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970
Mailing Address - Country:US
Mailing Address - Phone:800-750-8616
Mailing Address - Fax:845-362-8474
Practice Address - Street 1:130 E 18TH ST LBBY 1U
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2416
Practice Address - Country:US
Practice Address - Phone:212-674-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant