Basic Information
Provider Information | |||||||||
NPI: | 1982024154 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STILES | ||||||||
FirstName: | LYNNETTE | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RNC-IBCLC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 600 | ||||||||
Address2: | PPS BUSINESS OFFICE | ||||||||
City: | TUBA CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 860450600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282832781 | ||||||||
FaxNumber: | 9282832677 | ||||||||
Practice Location | |||||||||
Address1: | 167 NORTH MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | TUBA CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 860450600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282832501 | ||||||||
FaxNumber: | 9282832677 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2014 | ||||||||
LastUpdateDate: | 05/29/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 165443-30 | WI | Y |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 03-666262 | CT | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 608203 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | RN9220737 | FL | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 026.0028762 | VT | N |   | Nursing Service Providers | Registered Nurse |   | 163WM0102X | R92090-2 | MN | N |   | Nursing Service Providers | Registered Nurse | Maternal Newborn | 163WM0102X | 14957 IBCLC | VA | N |   | Nursing Service Providers | Registered Nurse | Maternal Newborn | 163WX0003X | STI104300163 | AR | N |   | Nursing Service Providers | Registered Nurse | Obstetric, Inpatient | 174N00000X | 196-13641 |   | N |   | Other Service Providers | Lactation Consultant, Non-RN |   |
No ID Information.