Provider Demographics
NPI:1073884904
Name:SULLIVAN, LILA
Entity Type:Individual
Prefix:
First Name:LILA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 W SOUTH 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-9595
Mailing Address - Country:US
Mailing Address - Phone:217-774-2113
Mailing Address - Fax:
Practice Address - Street 1:1810 W SOUTH 3RD ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-9595
Practice Address - Country:US
Practice Address - Phone:217-774-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043069581164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse