Provider Demographics
NPI:1649802315
Name:LYLE, MARY REBECCA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:REBECCA
Last Name:LYLE
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 1:1087 MERRITT RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-3243
Mailing Address - Country:US
Mailing Address - Phone:678-895-2620
Mailing Address - Fax:
Practice Address - Street 1:35 COLLIER RD NW STE 635
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1611
Practice Address - Country:US
Practice Address - Phone:404-367-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN210107363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner