Provider Demographics
NPI:1083768824
Name:NYDAM, LILA SUE (BA)
Entity Type:Individual
Prefix:
First Name:LILA
Middle Name:SUE
Last Name:NYDAM
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 SUNVALE DR SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-6551
Mailing Address - Country:US
Mailing Address - Phone:616-257-3727
Mailing Address - Fax:
Practice Address - Street 1:781 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-2319
Practice Address - Country:US
Practice Address - Phone:616-248-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator