Provider Demographics
NPI:1962459958
Name:LYDIC, MICHELE H (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:H
Last Name:LYDIC
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:H
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1622 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6613
Mailing Address - Country:US
Mailing Address - Phone:330-399-7215
Mailing Address - Fax:330-399-2411
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-480-3658
Practice Address - Fax:330-480-3439
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN354636L367500000X
OHRN287081-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016766170001Medicaid
OH8247171OtherMEDICARE PTAN
OH2822762Medicaid
OH8247171OtherMEDICARE PTAN