Provider Demographics
NPI:1003290206
Name:LILLY, AMANDA NICOLE (CNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:LILLY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2633
Mailing Address - Country:US
Mailing Address - Phone:419-522-6191
Mailing Address - Fax:419-525-6723
Practice Address - Street 1:600 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2633
Practice Address - Country:US
Practice Address - Phone:419-522-6191
Practice Address - Fax:419-525-6723
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP17720363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily