Healthcare Provider Details

I. General information

NPI: 1962459958
Provider Name (Legal Business Name): MICHELE H LYDIC CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE H KING CRNA

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 BELMONT AVE
YOUNGSTOWN OH
44504-1006
US

IV. Provider business mailing address

1622 E MARKET ST
WARREN OH
44483-6613
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-3658
  • Fax: 330-480-3439
Mailing address:
  • Phone: 330-399-7215
  • Fax: 330-399-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN354636L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN287081-1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: