Provider Demographics
NPI:1083493563
Name:WEISS, LILY COLETTE (RADT-1)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:COLETTE
Last Name:WEISS
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 MOUNT HERBERT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4724
Mailing Address - Country:US
Mailing Address - Phone:619-609-6379
Mailing Address - Fax:
Practice Address - Street 1:7986 DAGGET ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2321
Practice Address - Country:US
Practice Address - Phone:858-262-8539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1519520823172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker