Provider Demographics
NPI:1063297315
Name:LYTWYN, JILL MARIE
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:LYTWYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10980 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-4686
Mailing Address - Country:US
Mailing Address - Phone:612-425-9145
Mailing Address - Fax:
Practice Address - Street 1:9850 51ST AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-3270
Practice Address - Country:US
Practice Address - Phone:612-425-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1163971835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric