Basic Information
| Provider Information | |||||||||
| NPI: | 1013661230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYLES | ||||||||
| FirstName: | RAVEN | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 OLD SPANISH TRL | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392123210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014051782 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043844274 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2022 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 6828 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.