Provider Demographics
NPI:1093729824
Name:WILSON, LYDIA KAY (GNP)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17075 DEVONSHIRE ST
Mailing Address - Street 2:STE 204
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5408
Mailing Address - Country:US
Mailing Address - Phone:818-368-8929
Mailing Address - Fax:
Practice Address - Street 1:18855 VICTORY BLVD
Practice Address - Street 2:ATTN: BILLING DEPARTMENT
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6445
Practice Address - Country:US
Practice Address - Phone:818-774-3354
Practice Address - Fax:818-757-4401
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513626363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11725OtherN.P. FURNISHING
CA513626OtherSTATE LICENSE #
CAP00705925OtherRAILROAD MEDICARE
CAP00705925OtherRAILROAD MEDICARE
CAMW-071236OtherDEA #