Provider Demographics
NPI:1174880090
Name:LYSTER, DANIELLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:LYSTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DOON RD
Mailing Address - Street 2:
Mailing Address - City:UNDERHILL
Mailing Address - State:VT
Mailing Address - Zip Code:05489-9732
Mailing Address - Country:US
Mailing Address - Phone:028-922-5150
Mailing Address - Fax:
Practice Address - Street 1:133 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1726
Practice Address - Country:US
Practice Address - Phone:802-524-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-17
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.00852442255A2300X
NY024052363A00000X
VT055.0031570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer