Provider Demographics
NPI:1366468506
Name:LYDA, GAYLENE (RNFA)
Entity Type:Individual
Prefix:
First Name:GAYLENE
Middle Name:
Last Name:LYDA
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 W HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2608
Mailing Address - Country:US
Mailing Address - Phone:541-673-8988
Mailing Address - Fax:541-672-8103
Practice Address - Street 1:2801 NW MERCY DR
Practice Address - Street 2:SUITE 330
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2348
Practice Address - Country:US
Practice Address - Phone:541-677-3600
Practice Address - Fax:541-677-3601
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR80012252163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR090461Medicaid