Provider Demographics
NPI:1003898487
Name:JOHNSON, LILLY ROSE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LILLY
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:LILLY
Other - Middle Name:ROSE
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 LIGGETT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-1228
Mailing Address - Country:US
Mailing Address - Phone:913-364-4454
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000062093164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse