Provider Demographics
NPI:1659177699
Name:LYDIA POTOMA LLC
Entity type:Organization
Organization Name:LYDIA POTOMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:POTOMA
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, CNP
Authorized Official - Phone:216-403-1291
Mailing Address - Street 1:18051 JEFFERSON PARK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3460
Mailing Address - Country:US
Mailing Address - Phone:216-403-1291
Mailing Address - Fax:
Practice Address - Street 1:18051 JEFFERSON PARK RD STE 102
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3460
Practice Address - Country:US
Practice Address - Phone:216-403-1291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty