Healthcare Provider Details

I. General information

NPI: 1639695976
Provider Name (Legal Business Name): LYDIA M DYSART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR
YPSILANTI, MI 48197 MI
48197
US

IV. Provider business mailing address

5333 MCAULEY DR
YPSILANTI MI
48197-1014
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-7242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: