Provider Demographics
NPI:1770073231
Name:LYLES, SHANTWANA S
Entity type:Individual
Prefix:
First Name:SHANTWANA
Middle Name:S
Last Name:LYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTWANA
Other - Middle Name:S
Other - Last Name:LYLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SHANTWANA S LYLES
Mailing Address - Street 1:2807 FOREST HOLLOW LN APT 3313
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-3020
Mailing Address - Country:US
Mailing Address - Phone:909-485-2273
Mailing Address - Fax:
Practice Address - Street 1:2807 FOREST HOLLOW LN APT 3313
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-3020
Practice Address - Country:US
Practice Address - Phone:909-485-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK546154224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist