MEDICARE: RENEE ELISE LYDIARD

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	363LF0000X	Family Nurse Practitioner	266838	AZ

General Provider Information

NPI Number	:	1144987793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE ELISE LYDIARD

Provider Business Mailing Address
First Line	:	4213 E AVALON DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-7207
Country	:	US
Telephone Number	:	602-692-7810
Fax Number	:

Provider Business Practice Location Address
First Line	:	4213 E AVALON DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-7207
Country	:	US
Telephone Number	:	602-692-7810
Fax Number	:

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

Provider Enumeration Date	:	11/18/2021
Last Update Date	:	12/21/2021

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Directions to “ RENEE ELISE LYDIARD ” Practice Location

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