Provider Demographics
NPI:1689732679
Name:LYKINS, SUSAN RENEE (SAC,PAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:LYKINS
Suffix:
Gender:F
Credentials:SAC,PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 FONTAINE CIR # B
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-1948
Mailing Address - Country:US
Mailing Address - Phone:859-619-1515
Mailing Address - Fax:859-268-0308
Practice Address - Street 1:265 FONTAINE CIR # B
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-1948
Practice Address - Country:US
Practice Address - Phone:859-619-1515
Practice Address - Fax:859-268-0308
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA101246ZC0007X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant