Provider Demographics
NPI:1871678995
Name:WILLIAMS, LYSTRA EASTLYN (CRNP)
Entity Type:Individual
Prefix:
First Name:LYSTRA
Middle Name:EASTLYN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 W ROLLING XRDS STE 111
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-6204
Mailing Address - Country:US
Mailing Address - Phone:410-788-6727
Mailing Address - Fax:410-788-6729
Practice Address - Street 1:7310 RITCHIE HWY STE 405
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-788-6727
Practice Address - Fax:410-788-6727
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR132674363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD011706400Medicaid