Healthcare Provider Details

I. General information

NPI: 1114736667
Provider Name (Legal Business Name): LYDIA G ANDEMARIAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13851 E 14TH ST STE 206
SAN LEANDRO CA
94578-2627
US

IV. Provider business mailing address

13851 E 14TH ST STE 206
SAN LEANDRO CA
94578-2627
US

V. Phone/Fax

Practice location:
  • Phone: 510-351-9373
  • Fax:
Mailing address:
  • Phone: 510-351-9373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95030075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: