Provider Demographics
NPI:1578585162
Name:TEAGUE, LYDIA M
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LYDIA
Other - Middle Name:M
Other - Last Name:TEAGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:4 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110
Mailing Address - Country:US
Mailing Address - Phone:501-977-2300
Mailing Address - Fax:501-977-2256
Practice Address - Street 1:4 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110
Practice Address - Country:US
Practice Address - Phone:501-977-2300
Practice Address - Fax:501-977-2256
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR25489163W00000X
ARC00401367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136786701Medicaid
R08671Medicare UPIN
AR136786701Medicaid