Provider Demographics
NPI:1114964087
Name:LILES, JOANNE D (NP)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:D
Last Name:LILES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 CEDAR POINT BLVD
Mailing Address - Street 2:UNIT D
Mailing Address - City:CEDAR POINT
Mailing Address - State:NC
Mailing Address - Zip Code:28584-8020
Mailing Address - Country:US
Mailing Address - Phone:252-764-2121
Mailing Address - Fax:252-764-2135
Practice Address - Street 1:1057 CEDAR POINT BLVD
Practice Address - Street 2:UNIT D
Practice Address - City:CEDAR POINT
Practice Address - State:NC
Practice Address - Zip Code:28584-8020
Practice Address - Country:US
Practice Address - Phone:252-764-2121
Practice Address - Fax:252-764-2135
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201471363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003903Medicaid
NCDF8530OtherRAILROAD MEDICARE
NC2592099AMedicare PIN
NCDF8530OtherRAILROAD MEDICARE