Healthcare Provider Details

I. General information

NPI: 1679582290
Provider Name (Legal Business Name): LYDIA J GLADWIN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5139 US HIGHWAY 19
NEW PORT RICHEY FL
34652-3966
US

IV. Provider business mailing address

P O BOX 406153
ATLANTA GA
30384-1876
US

V. Phone/Fax

Practice location:
  • Phone: 727-849-6076
  • Fax: 727-848-2830
Mailing address:
  • Phone: 727-849-6076
  • Fax: 727-848-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY1140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: