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NPI Code Detail

MEDICARE: MS. LYDIA KAY WILSON GNP

MEDICARE: MS. LYDIA KAY WILSON GNP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LG0600XGerontology Nurse Practitioner513626CA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
3P00705925OTHERCARAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
111725OTHERCAN.P. FURNISHING
2513626OTHERCASTATE LICENSE #

General Provider Information

NPI Number : 1093729824
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. LYDIA KAY WILSON GNP
Provider Business Mailing Address
First Line : 17075 DEVONSHIRE ST
Second Line : STE 204
City : NORTHRIDGE
State : CA
Zip : 91325-5408
Country : US
Telephone Number : 818-368-8929
Fax Number :
Provider Business Practice Location Address
First Line : 18855 VICTORY BLVD
Second Line : ATTN: BILLING DEPARTMENT
City : RESEDA
State : CA
Zip : 91335-6445
Country : US
Telephone Number : 818-774-3354
Fax Number : 818-757-4401
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2006
Last Update Date : 03/07/2023

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