Basic Information
| Provider Information | |||||||||
| NPI: | 1164719738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYELL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975311 | ||||||||
| FaxNumber: | 6189985668 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975311 | ||||||||
| FaxNumber: | 6189985668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2011 | ||||||||
| LastUpdateDate: | 04/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 209-008558 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.