Provider Demographics
NPI:1275916058
Name:ELLIOTT, LYDIA (APRN-CNM)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:APRN-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2899
Mailing Address - Country:US
Mailing Address - Phone:864-522-8611
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK RD STE 107
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-434-4480
Practice Address - Fax:803-434-3340
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19531367A00000X
GARN294300367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034164AMedicaid
GAGRP3569OtherMEDICARE OPT-OUT