MEDICARE: LYDIA KAWUDHA PMHNP-BC

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
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024191086	VA

General Provider Information

NPI Number	:	1528895398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA KAWUDHA PMHNP-BC

Provider Business Mailing Address
First Line	:	3330 BOURBON ST
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22408-7333
Country	:	US
Telephone Number	:	540-782-3620
Fax Number	:	540-227-4591

Provider Business Practice Location Address
First Line	:	3330 BOURBON ST
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22408-7333
Country	:	US
Telephone Number	:	540-782-3620
Fax Number	:	540-227-4591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2024
Last Update Date	:	04/09/2026

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