Provider Demographics
NPI:1952726275
Name:MCCANTS, LYDIA
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:MCCANTS
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 1:321 N DE VILLIERS ST
Mailing Address - Street 2:UNIT 219
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-3890
Mailing Address - Country:US
Mailing Address - Phone:850-485-1302
Mailing Address - Fax:
Practice Address - Street 1:321 N DE VILLIERS ST
Practice Address - Street 2:UNIT 219
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3890
Practice Address - Country:US
Practice Address - Phone:850-485-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233121172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006394100Medicaid