Provider Demographics
NPI:1114035516
Name:LILLY, JACQUELINE DIANE (PHD APRN BC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANE
Last Name:LILLY
Suffix:
Gender:F
Credentials:PHD APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WEST UTICA STREET
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126
Mailing Address - Country:US
Mailing Address - Phone:315-342-2450
Mailing Address - Fax:
Practice Address - Street 1:102 WEST UTICA STREET
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-342-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRN2539751364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7493000OtherVALUE OPTIONS
IA1165Medicare UPIN