Provider Demographics
NPI:1902422595
Name:LILLEY, CARLY ANNE
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANNE
Last Name:LILLEY
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 1:205 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-1946
Mailing Address - Country:US
Mailing Address - Phone:401-207-7253
Mailing Address - Fax:
Practice Address - Street 1:205 LINDEN DR
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-1946
Practice Address - Country:US
Practice Address - Phone:401-207-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide