Provider Demographics
NPI:1013194380
Name:LILLYWYTE LLC
Entity Type:Organization
Organization Name:LILLYWYTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JATANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-944-4085
Mailing Address - Street 1:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:TX
Mailing Address - Zip Code:77532-1288
Mailing Address - Country:US
Mailing Address - Phone:281-462-1285
Mailing Address - Fax:281-462-1554
Practice Address - Street 1:8418 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-9738
Practice Address - Country:US
Practice Address - Phone:281-462-1285
Practice Address - Fax:281-462-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2612363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty