1346510716 NPI number — MR. JOHN WAYNE LILLY JR. APRN, FNP-BC

Table of content: MR. JOHN WAYNE LILLY JR. APRN, FNP-BC (NPI 1346510716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346510716 NPI number — MR. JOHN WAYNE LILLY JR. APRN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILLY
Provider First Name:
JOHN
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
APRN, FNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LILLY
Provider Other First Name:
JOHN
Provider Other Middle Name:
WAYNE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, FNP-BC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1346510716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 N EISENHOWER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BECKLEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25801-4141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-929-0786
Provider Business Mailing Address Fax Number:
304-929-2278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N. EISENHOWER DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BECKLEY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25801-3140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-929-0786
Provider Business Practice Location Address Fax Number:
304-929-2278
Provider Enumeration Date:
01/03/2012

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: 363LF0000X , with the licence number:  64742 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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