Provider Demographics
NPI:1023200193
Name:LILLY, MARSHA C (MS/RD/LDN)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:C
Last Name:LILLY
Suffix:
Gender:F
Credentials:MS/RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 RANGECREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-6922
Mailing Address - Country:US
Mailing Address - Phone:919-848-8402
Mailing Address - Fax:
Practice Address - Street 1:2101 RANGECREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-6922
Practice Address - Country:US
Practice Address - Phone:919-848-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000032133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal