Provider Demographics
NPI:1770025868
Name:LYTLE, ANGELA (FNP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:LYTLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162 BOX 215
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-391-6405
Mailing Address - Fax:618-288-4088
Practice Address - Street 1:1 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5068
Practice Address - Country:US
Practice Address - Phone:618-463-8500
Practice Address - Fax:618-463-8537
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015110363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner