Provider Demographics
NPI:1255750626
Name:JOHNSON, LYDIA ZIMMER (RN)
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:ZIMMER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5613 DURALEIGH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2694
Mailing Address - Country:US
Mailing Address - Phone:919-782-4597
Mailing Address - Fax:919-784-0089
Practice Address - Street 1:5613 DURALEIGH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2694
Practice Address - Country:US
Practice Address - Phone:919-782-4597
Practice Address - Fax:919-784-0089
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011443363L00000X, 363LP0808X
NC261954163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health