Provider Demographics
NPI:1891059622
Name:LYTLE, MISTY DAWN (FNP-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:LYTLE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9411 N LAMAR BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-4179
Mailing Address - Country:US
Mailing Address - Phone:512-583-9679
Mailing Address - Fax:512-233-0985
Practice Address - Street 1:9411 N LAMAR BLVD STE 120
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-4179
Practice Address - Country:US
Practice Address - Phone:512-744-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX670751363LF0000X
TXAP121315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3530701-01Medicaid