Provider Demographics
NPI:1558097089
Name:BREAUX, LYDIA KATHERINE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:KATHERINE
Last Name:BREAUX
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:PO BOX 100 DEPT#394
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:941-300-4440
Mailing Address - Fax:941-404-1760
Practice Address - Street 1:201 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-3079
Practice Address - Country:US
Practice Address - Phone:561-867-9991
Practice Address - Fax:800-755-8631
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021004363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115219300Medicaid