Provider Demographics
NPI:1932680105
Name:LYDICK, AUTUMN N (AGACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:N
Last Name:LYDICK
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 CLEAR FALLS DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1962
Mailing Address - Country:US
Mailing Address - Phone:409-749-4193
Mailing Address - Fax:
Practice Address - Street 1:504 MEDICAL CENTER BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:936-523-0230
Practice Address - Fax:936-647-2292
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138586363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care