Provider Demographics
NPI:1700650462
Name:JANNAH, LYDIA TITY
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:TITY
Last Name:JANNAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FLEWELLEN DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-7829
Mailing Address - Country:US
Mailing Address - Phone:571-477-8097
Mailing Address - Fax:
Practice Address - Street 1:14090 BIG CREST LN APT 207
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5531
Practice Address - Country:US
Practice Address - Phone:157-477-8097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care