Provider Demographics
NPI:1922190651
Name:LYON, RENEE C (ARNP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:C
Last Name:LYON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4201
Mailing Address - Country:US
Mailing Address - Phone:253-564-4157
Mailing Address - Fax:253-564-4813
Practice Address - Street 1:4401 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4201
Practice Address - Country:US
Practice Address - Phone:253-564-4157
Practice Address - Fax:253-564-4813
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00157089163W00000X
WAAP30007419363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9650235Medicaid
WA0213407OtherSTATE L&I
WA0222891OtherSTATE L&I
WA8943195OtherSTATE CRIME VICTIMS
WA8945094OtherSTATE CRIME VICTIMS
WA0222891OtherSTATE L&I
WAG8865273Medicare PIN
WAG8865914Medicare PIN