Provider Demographics
NPI:1538535562
Name:MLECZKO, LILIA MARINA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:LILIA
Middle Name:MARINA
Last Name:MLECZKO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MRS
Other - First Name:LILIA
Other - Middle Name:MARINA
Other - Last Name:SANTISTEBAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:1333 IMLAY CITY RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3113
Mailing Address - Country:US
Mailing Address - Phone:248-952-4343
Mailing Address - Fax:
Practice Address - Street 1:32270 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2456
Practice Address - Country:US
Practice Address - Phone:248-792-9496
Practice Address - Fax:248-792-9628
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704246238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1538535562OtherLILIA M. MLECZKO