Provider Demographics
NPI:1063007854
Name:LILLYS MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:LILLYS MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:
Authorized Official - First Name:GEORGETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PROVOST-DUKES
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:407-719-5723
Mailing Address - Street 1:4241 BAYMEADOWS RD STE 6
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4673
Mailing Address - Country:US
Mailing Address - Phone:407-719-5723
Mailing Address - Fax:
Practice Address - Street 1:4241 BAYMEADOWS RD STE 6
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4673
Practice Address - Country:US
Practice Address - Phone:407-719-5723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty