Provider Demographics
NPI:1376168336
Name:NICODEMUS, LYDA ERIN (ARNP)
Entity Type:Individual
Prefix:
First Name:LYDA
Middle Name:ERIN
Last Name:NICODEMUS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S SHERMAN ST # 201
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1311
Mailing Address - Country:US
Mailing Address - Phone:509-473-0885
Mailing Address - Fax:
Practice Address - Street 1:9631 N NEVADA ST STE 300
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1193
Practice Address - Country:US
Practice Address - Phone:509-465-3919
Practice Address - Fax:509-795-0895
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61025822363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner