Provider Demographics
NPI:1053720185
Name:EVELSIZER, LYDIA
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:EVELSIZER
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 1:665 GILLMER RD
Mailing Address - Street 2:
Mailing Address - City:LEAVITTSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44430-9683
Mailing Address - Country:US
Mailing Address - Phone:330-307-5516
Mailing Address - Fax:
Practice Address - Street 1:665 GILLMER RD
Practice Address - Street 2:
Practice Address - City:LEAVITTSBURG
Practice Address - State:OH
Practice Address - Zip Code:44430-9683
Practice Address - Country:US
Practice Address - Phone:330-307-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-02
Last Update Date:2014-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2906001Medicaid