Provider Demographics
NPI:1871356667
Name:BRANDT, LYDIA GRACE
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:GRACE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MONTE ENEBRO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-2784
Mailing Address - Country:US
Mailing Address - Phone:307-380-6276
Mailing Address - Fax:
Practice Address - Street 1:455 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-913-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM872367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife