Provider Demographics
NPI:1912788092
Name:LYDIC, JERRAMI (ACNPC-AG)
Entity Type:Individual
Prefix:MR
First Name:JERRAMI
Middle Name:
Last Name:LYDIC
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4935 HOPKINS RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-3623
Mailing Address - Country:US
Mailing Address - Phone:330-716-4380
Mailing Address - Fax:
Practice Address - Street 1:4935 HOPKINS RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-3623
Practice Address - Country:US
Practice Address - Phone:330-716-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN716224363LA2100X
OHAPRN.CNP.0035160363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care