Provider Demographics
NPI:1982206769
Name:LIDGE, NANCY JEAN
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JEAN
Last Name:LIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44306-2029
Mailing Address - Country:US
Mailing Address - Phone:330-813-0219
Mailing Address - Fax:
Practice Address - Street 1:732 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44306-2029
Practice Address - Country:US
Practice Address - Phone:330-813-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN519412172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0333153Medicaid
OH0000257313OtherDODD SUPPLIER ID 0000257313
OH0313104Medicaid