Provider Demographics
NPI:1174262554
Name:LIDY, ANNETTA (CD, CBC)
Entity Type:Individual
Prefix:
First Name:ANNETTA
Middle Name:
Last Name:LIDY
Suffix:
Gender:F
Credentials:CD, CBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904-1435
Mailing Address - Country:US
Mailing Address - Phone:609-240-8976
Mailing Address - Fax:
Practice Address - Street 1:134 ADAMS RD
Practice Address - Street 2:
Practice Address - City:PORT DEPOSIT
Practice Address - State:MD
Practice Address - Zip Code:21904-1435
Practice Address - Country:US
Practice Address - Phone:609-240-8976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD174N00000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN