Healthcare Provider Details

I. General information

NPI: 1164828406
Provider Name (Legal Business Name): LYDIA JILL YEAGER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 BROADWAY FL 14
NEW YORK NY
10006-2516
US

IV. Provider business mailing address

65 BROADWAY FL 14
NEW YORK NY
10006-2516
US

V. Phone/Fax

Practice location:
  • Phone: 212-348-4000
  • Fax:
Mailing address:
  • Phone: 212-348-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number382502
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: