Provider Demographics
NPI:1285212803
Name:FENNESSY, LYDIA
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:FENNESSY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 GREENLEAF DR
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-1153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 NOLTE DR
Practice Address - Street 2:
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-7111
Practice Address - Country:US
Practice Address - Phone:724-543-8657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical