Provider Demographics
NPI:1699393983
Name:LYON, ANDREA R (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:LYON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:R
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 1021
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-6021
Mailing Address - Country:US
Mailing Address - Phone:906-309-0158
Mailing Address - Fax:906-299-5067
Practice Address - Street 1:N3116 S 1 DR
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:MI
Practice Address - Zip Code:49893-9627
Practice Address - Country:US
Practice Address - Phone:906-309-0158
Practice Address - Fax:906-299-5067
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist