Healthcare Provider Details

I. General information

NPI: 1255514758
Provider Name (Legal Business Name): MARY ELLEN LYDEM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 BERKSHIRE BLVD
BETHEL CT
06801-1001
US

IV. Provider business mailing address

4 BERKSHIRE BLVD
BETHEL CT
06801-1001
US

V. Phone/Fax

Practice location:
  • Phone: 203-826-3159
  • Fax: 203-775-6810
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number001563
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: