Healthcare Provider Details

I. General information

NPI: 1174976856
Provider Name (Legal Business Name): LYDIA MARIE DOMINIC CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 KIRKPATRICK RD
BURLINGTON NC
27215-9714
US

IV. Provider business mailing address

1091 KIRKPATRICK RD
BURLINGTON NC
27215-9714
US

V. Phone/Fax

Practice location:
  • Phone: 336-538-1880
  • Fax: 336-538-1895
Mailing address:
  • Phone: 336-538-1880
  • Fax: 336-538-1895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number231729
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number607
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: