1295243590 NPI number — STACIE LILLY ARNP

Table of content: STACIE LILLY ARNP (NPI 1295243590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295243590 NPI number — STACIE LILLY ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILLY
Provider First Name:
STACIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295243590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16975 SE 27TH PLACE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCKLAWAHA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32179-2323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-598-7662
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 SW 46TH CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34474-5708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-291-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  9278130 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 9278130 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 119263600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".