Provider Demographics
NPI:1689151227
Name:LYTLE, SERENA LYNN (ATC)
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:LYNN
Last Name:LYTLE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-2644
Mailing Address - Country:US
Mailing Address - Phone:316-650-4034
Mailing Address - Fax:
Practice Address - Street 1:620 S RICHMOND ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213-2644
Practice Address - Country:US
Practice Address - Phone:316-650-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer