Provider Demographics
NPI:1205721909
Name:PAUL, LYSTRA
Entity type:Individual
Prefix:
First Name:LYSTRA
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15447 ANACAPA RD STE 102D2
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2481
Mailing Address - Country:US
Mailing Address - Phone:909-654-0798
Mailing Address - Fax:800-915-8151
Practice Address - Street 1:15447 ANACAPA RD STE 102D2
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2481
Practice Address - Country:US
Practice Address - Phone:909-654-0798
Practice Address - Fax:800-915-8151
Is Sole Proprietor?:No
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker