Provider Demographics
NPI:1114736667
Name:ANDEMARIAM, LYDIA G (NP)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:G
Last Name:ANDEMARIAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13851 E 14TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2627
Mailing Address - Country:US
Mailing Address - Phone:510-351-9373
Mailing Address - Fax:
Practice Address - Street 1:13851 E 14TH ST STE 206
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2627
Practice Address - Country:US
Practice Address - Phone:510-351-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95030075363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily