Provider Demographics
NPI:1063780955
Name:LIDES, MEGHAN KATHLEEN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:KATHLEEN
Last Name:LIDES
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MRS
Other - First Name:MEGHAN
Other - Middle Name:KATHLEEN
Other - Last Name:LIDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:7559 263RD ST
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1150
Mailing Address - Country:US
Mailing Address - Phone:917-749-9440
Mailing Address - Fax:
Practice Address - Street 1:7559 263RD ST
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1150
Practice Address - Country:US
Practice Address - Phone:917-749-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY407512363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03008151Medicaid