Provider Demographics
NPI:1437486297
Name:HATHORN, LYDIA VINCENT (MSN, RN, WHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:VINCENT
Last Name:HATHORN
Suffix:
Gender:F
Credentials:MSN, RN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5646 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6429
Mailing Address - Country:US
Mailing Address - Phone:314-606-8521
Mailing Address - Fax:
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-5306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-14
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420963363LW0102X
TXAP131236363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health