Provider Demographics
NPI:1730237876
Name:LYDON, SALLY ANN (CRNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:LYDON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:770 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAND COULEE
Mailing Address - State:MT
Mailing Address - Zip Code:59472-9749
Mailing Address - Country:US
Mailing Address - Phone:406-736-5797
Mailing Address - Fax:
Practice Address - Street 1:115 4TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3618
Practice Address - Country:US
Practice Address - Phone:406-454-6973
Practice Address - Fax:406-454-6986
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN20118363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTQ37252Medicare UPIN