Provider Demographics
NPI:1548471642
Name:LILLY, JEANETTE DAWN (PT)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:DAWN
Last Name:LILLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7655 115TH ST
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-5304
Mailing Address - Country:US
Mailing Address - Phone:727-398-8801
Mailing Address - Fax:727-521-5597
Practice Address - Street 1:6006 49TH ST N
Practice Address - Street 2:SUITE 240
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2148
Practice Address - Country:US
Practice Address - Phone:727-521-5031
Practice Address - Fax:727-521-5597
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist