Provider Demographics
NPI:1144088709
Name:LYLE, JENNIFER (RD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LYLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CONGRESSIONAL LN
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-8568
Mailing Address - Country:US
Mailing Address - Phone:845-537-9131
Mailing Address - Fax:
Practice Address - Street 1:300 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:PA
Practice Address - Zip Code:15074-2165
Practice Address - Country:US
Practice Address - Phone:724-709-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1033285133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered