Provider Demographics
NPI:1609830884
Name:HARRIS, LYDIA J (NNP)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6451 N FEDERAL HWY STE 700
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1420
Mailing Address - Country:US
Mailing Address - Phone:855-808-2723
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2273
Practice Address - Fax:207-662-6324
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2451363LN0005X
GARN081306363LN0005X
MECNP241194363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA32869766AMedicaid