MEDICARE: LYDIA LOUISE CLARK-SUMPTER PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	381663	NY

General Provider Information

NPI Number	:	1023402401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA LOUISE CLARK-SUMPTER PNP

Provider Business Mailing Address
First Line	:	2588 7TH AVE
Second Line	:	APT 5C
City	:	NEW YORK
State	:	NY
Zip	:	10039-2605
Country	:	US
Telephone Number	:	917-251-2912
Fax Number	:

Provider Business Practice Location Address
First Line	:	2588 7TH AVE
Second Line	:	APT 5C
City	:	NEW YORK
State	:	NY
Zip	:	10039-2605
Country	:	US
Telephone Number	:	917-251-2912
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	03/24/2015

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