Healthcare Provider Details

I. General information

NPI: 1093758682
Provider Name (Legal Business Name): DIANE H LYDDON RN, APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-2020
  • Fax: 479-750-4843
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-4843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR15892
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberA01095
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: