Provider Demographics
NPI:1063646388
Name:MEAD, LILLY VILLALOBOS (RD)
Entity Type:Individual
Prefix:MRS
First Name:LILLY
Middle Name:VILLALOBOS
Last Name:MEAD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 GOLF HOUSE RD E
Mailing Address - Street 2:
Mailing Address - City:WHITSETT
Mailing Address - State:NC
Mailing Address - Zip Code:27377-9204
Mailing Address - Country:US
Mailing Address - Phone:336-449-0838
Mailing Address - Fax:
Practice Address - Street 1:807 GOLF HOUSE RD E
Practice Address - Street 2:
Practice Address - City:WHITSETT
Practice Address - State:NC
Practice Address - Zip Code:27377-9204
Practice Address - Country:US
Practice Address - Phone:336-449-0838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001925133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP78576Medicare UPIN