Provider Demographics
NPI:1164913059
Name:LYDIA, DOMINIQUE YVETTE (RN)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:YVETTE
Last Name:LYDIA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:DOMINIQUE
Other - Middle Name:YVETTE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3303 W ILLINOIS AVE STE 22
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-6232
Mailing Address - Country:US
Mailing Address - Phone:432-681-7613
Mailing Address - Fax:
Practice Address - Street 1:3303 W ILLINOIS AVE STE 22
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-6232
Practice Address - Country:US
Practice Address - Phone:432-681-7613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX939045163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health