Provider Demographics
NPI:1679844377
Name:DAVID, LYDIA (CHP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:DAVID
Suffix:
Gender:F
Credentials:CHP
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 339
Mailing Address - Street 2:
Mailing Address - City:TOK
Mailing Address - State:AK
Mailing Address - Zip Code:99780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EASTON RD. # 303
Practice Address - Street 2:
Practice Address - City:TETLIN
Practice Address - State:AK
Practice Address - Zip Code:99776
Practice Address - Country:US
Practice Address - Phone:907-324-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK06-770-P172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker