Provider Demographics
NPI:1609830884
Name:HARRIS, LYDIA J (NNP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 WATERS AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6200
Mailing Address - Country:US
Mailing Address - Phone:912-350-9380
Mailing Address - Fax:912-350-5930
Practice Address - Street 1:4750 WATERS AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6200
Practice Address - Country:US
Practice Address - Phone:912-350-9380
Practice Address - Fax:912-350-5930
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN081306363LN0005X
WI2451363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA32869766AMedicaid