Basic Information
| Provider Information | |||||||||
| NPI: | 1679205322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HYLAND | ||||||||
| FirstName: | MATTIE | ||||||||
| MiddleName: | HELEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNLAP | ||||||||
| OtherFirstName: | MATTIE | ||||||||
| OtherMiddleName: | HELEN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 495 W 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432013176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012883254 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 106 STARRET ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431303993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406870042 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2022 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OH | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.