Provider Demographics
NPI:1972834422
Name:COMMISSARIS, LYDIA J (FNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:LYDIA
Middle Name:J
Last Name:COMMISSARIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 GREENLEAF DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1170
Mailing Address - Country:US
Mailing Address - Phone:248-548-5772
Mailing Address - Fax:
Practice Address - Street 1:45 W. GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226
Practice Address - Country:US
Practice Address - Phone:313-585-4734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704177563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily