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General NPI Number Information
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NPI Number | 1659177699
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Entity Type | Organization
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Legal Business Name | LYDIA POTOMA LLC
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Dates
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Enumeration Date | 02/20/2025
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Last Update Date | 02/20/2025
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Provider Practice Location Address
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Address Line | 18051 JEFFERSON PARK RD STE 102
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City | MIDDLEBURG HEIGHTS
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State | OH
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Zip | 44130-3460
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Country | US
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Telephone | 216-403-1291
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Fax |
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Provider Business Mailing Address
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Address Line | 18051 JEFFERSON PARK RD STE 102
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City | MIDDLEBURG HEIGHTS
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State | OH
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Zip | 44130-3460
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Country | US
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Telephone | 216-403-1291
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LYDIA LEE POTOMA
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Credential | MSN, APRN, CNP
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Telephone | 216-403-1291
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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