1225107543 NPI number — MRS. TIFFANY MARIE LYTLE PT

Table of content: (NPI 1447447016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225107543 NPI number — MRS. TIFFANY MARIE LYTLE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYTLE
Provider First Name:
TIFFANY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HANNAKAN
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225107543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 SPRUCE CT
Provider Second Line Business Mailing Address:
APT 2
Provider Business Mailing Address City Name:
SALIX
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15952-9439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-487-5841
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 GOUCHER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15905-2942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-255-4921
Provider Business Practice Location Address Fax Number:
814-255-4921
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT017508 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HA1863318 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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