Provider Demographics
NPI:1952547234
Name:LYTLE, GRACE ELIZABETH (OD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ELIZABETH
Last Name:LYTLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1203
Mailing Address - Country:US
Mailing Address - Phone:617-417-2160
Mailing Address - Fax:
Practice Address - Street 1:940 COMMONWEALTH AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1203
Practice Address - Country:US
Practice Address - Phone:617-417-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4698152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist