Provider Demographics
NPI:1033524491
Name:LYTLE, AMY A (OD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:LYTLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5143
Mailing Address - Country:US
Mailing Address - Phone:307-742-2020
Mailing Address - Fax:307-742-8917
Practice Address - Street 1:2575 YORBA LINDA BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1615
Practice Address - Country:US
Practice Address - Phone:714-449-7401
Practice Address - Fax:717-992-7850
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT15004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist