Provider Demographics
NPI:1245385855
Name:DALEY, LYDIA LEE (PMHNP, BC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:LEE
Last Name:DALEY
Suffix:
Gender:F
Credentials:PMHNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 1259
Mailing Address - Street 2:223 N. ANDERSON DRIVE
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 N. ANDERSON DRIVE
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401
Practice Address - Country:US
Practice Address - Phone:478-289-2530
Practice Address - Fax:478-289-2532
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN048295364SP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1952451262Medicaid
GA000606383BMedicaid
GA89BBBDVMedicare PIN