Provider Demographics
NPI:1053966374
Name:LYALL, KIANNA NICOLE (CF-SLP)
Entity type:Individual
Prefix:
First Name:KIANNA
Middle Name:NICOLE
Last Name:LYALL
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:MRS
Other - First Name:KIANNA
Other - Middle Name:NICOLE
Other - Last Name:SIVILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CF-SLP
Mailing Address - Street 1:3221 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3333
Mailing Address - Country:US
Mailing Address - Phone:309-798-3721
Mailing Address - Fax:
Practice Address - Street 1:415 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-2755
Practice Address - Country:US
Practice Address - Phone:309-734-4915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242005449235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist