Provider Demographics
NPI:1083382469
Name:QUARLES, LILLIE RAYNICE
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:RAYNICE
Last Name:QUARLES
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:LIFESTANCE 5386 COX-SMITH RD SUITE A MASON 45040
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-2242
Mailing Address - Country:US
Mailing Address - Phone:513-972-5120
Mailing Address - Fax:
Practice Address - Street 1:5386 COX SMITH RD STE A
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-6803
Practice Address - Country:US
Practice Address - Phone:513-972-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0028788363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health