Provider Demographics
NPI:1720673171
Name:SCOTT-LYEW, MICCAL A (AGPC-NP)
Entity Type:Individual
Prefix:
First Name:MICCAL
Middle Name:A
Last Name:SCOTT-LYEW
Suffix:
Gender:F
Credentials:AGPC-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MOUNTAIN BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-2640
Mailing Address - Country:US
Mailing Address - Phone:908-574-1267
Mailing Address - Fax:
Practice Address - Street 1:28 VALLEY RD # 148
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2709
Practice Address - Country:US
Practice Address - Phone:973-559-4600
Practice Address - Fax:855-998-4358
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJO1148500363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care