Provider Demographics
NPI:1952530065
Name:LYLES, JACQUELINE DIANNE (RN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:DIANNE
Last Name:LYLES
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 1:175A CALEBS PATH
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-1036
Mailing Address - Country:US
Mailing Address - Phone:631-439-1448
Mailing Address - Fax:
Practice Address - Street 1:175A CALEBS PATH
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-1036
Practice Address - Country:US
Practice Address - Phone:631-439-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY571191163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical