Provider Demographics
NPI:1083484018
Name:NICHOLS, LYDIA MARIA (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:MARIA
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:MS
Other - First Name:LYDIA
Other - Middle Name:MARIA
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4730 MASSILLON RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-1166
Mailing Address - Country:US
Mailing Address - Phone:330-906-1480
Mailing Address - Fax:
Practice Address - Street 1:4730 MASSILLON RD
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-1166
Practice Address - Country:US
Practice Address - Phone:330-906-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No253Z00000XAgenciesIn Home Supportive Care
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1083484018Medicaid