Healthcare Provider Details

I. General information

NPI: 1487164703
Provider Name (Legal Business Name): LYDIA GRACE SEIBERT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N JACKSON ST
TULLAHOMA TN
37388-8259
US

IV. Provider business mailing address

122 WOLVERINE CT
SMYRNA TN
37167-6814
US

V. Phone/Fax

Practice location:
  • Phone: 615-971-0570
  • Fax:
Mailing address:
  • Phone: 615-971-0570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3694
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: