Provider Demographics
NPI:1295350809
Name:DOUGLAS, LYDIA MARIAH (CPM, LDM)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIAH
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CPM, LDM
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:MARIAH
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1453 REDWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5523
Mailing Address - Country:US
Mailing Address - Phone:541-916-8333
Mailing Address - Fax:
Practice Address - Street 1:1453 REDWOOD CIR
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5523
Practice Address - Country:US
Practice Address - Phone:541-916-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10208453176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
20060005OtherNORTH AMERICAN REGISTRY OF MIDWIVES
ORDEM-LD-10208453OtherOREGON STATE MIDWIFERY LICENSE NUMBER