Provider Demographics
NPI:1275916058
Name:ELLIOTT, LYDIA (APRN-CNM)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:APRN-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5780 PEACHTREE DUNWOODY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1513
Mailing Address - Country:US
Mailing Address - Phone:404-303-8035
Mailing Address - Fax:404-303-1325
Practice Address - Street 1:355 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2153
Practice Address - Country:US
Practice Address - Phone:706-369-0019
Practice Address - Fax:706-369-1989
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN294300367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3569OtherMEDICARE OPT-OUT
GA300034164AMedicaid