Basic Information
| Provider Information | |||||||||
| NPI: | 1316604838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | CHEYENNE | ||||||||
| MiddleName: | CIERRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LEESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714464014 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 N 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | LEESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714467144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372393334 | ||||||||
| FaxNumber: | 3372393336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2021 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | LA | Y | 193200000X MULTI-SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 710895055 | 05 | LA | MEDICAID |