Healthcare Provider Details

I. General information

NPI: 1306569991
Provider Name (Legal Business Name): JULIE LYDOLPH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 MALCOLM AVE
NEWPORT AR
72112-3668
US

IV. Provider business mailing address

PO BOX 2197
BATESVILLE AR
72503-2197
US

V. Phone/Fax

Practice location:
  • Phone: 870-512-2500
  • Fax: 870-512-2525
Mailing address:
  • Phone: 870-262-5545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number221590
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: