Provider Demographics
NPI:1255148136
Name:LYTLE, JENNIFER DARLENE (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DARLENE
Last Name:LYTLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FAWN LN
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-4201
Mailing Address - Country:US
Mailing Address - Phone:765-860-8424
Mailing Address - Fax:
Practice Address - Street 1:200 FAWN LN
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-4201
Practice Address - Country:US
Practice Address - Phone:765-860-8424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-14
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28194539A163W00000X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No163W00000XNursing Service ProvidersRegistered Nurse