Provider Demographics
NPI:1588770424
Name:LIDY, JUDITH (FNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:LIDY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:LIDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:506 W LINCOLN AVE
Mailing Address - Street 2:SUITE 200 A
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2453
Mailing Address - Country:US
Mailing Address - Phone:217-348-8727
Mailing Address - Fax:
Practice Address - Street 1:506 W LINCOLN AVE
Practice Address - Street 2:SUITE 200 A
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2453
Practice Address - Country:US
Practice Address - Phone:217-348-8727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000974363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK20506Medicare PIN
ILP64729Medicare UPIN