Provider Demographics
NPI:1194755470
Name:LIDY, CYNTHIA YVONNE (NP)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:YVONNE
Last Name:LIDY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-0481
Mailing Address - Country:US
Mailing Address - Phone:310-639-9363
Mailing Address - Fax:310-639-9251
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:605
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3513
Practice Address - Country:US
Practice Address - Phone:310-639-9363
Practice Address - Fax:310-639-9251
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN426211363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP0094780Medicaid