Provider Demographics
NPI: | 1164501177 |
---|---|
Name: | DECILLIS, LYNNETTE A |
Entity Type: | Individual |
Prefix: | MS |
First Name: | LYNNETTE |
Middle Name: | A |
Last Name: | DECILLIS |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | MS |
Other - First Name: | LYNNETTE |
Other - Middle Name: | A |
Other - Last Name: | WILLEMAIN |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 2350 GEARY BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN FRANCISCO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 94115-3305 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 415-833-4356 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2350 GEARY BLVD |
Practice Address - Street 2: | |
Practice Address - City: | SAN FRANCISCO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 94115-3305 |
Practice Address - Country: | US |
Practice Address - Phone: | 415-833-2000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-11-02 |
Last Update Date: | 2023-11-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | NP 13102 | 363LA2100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | RN518440 | Other | MEDICAL PROVIDER RENDERIN |
CA | (PIN):ZZZ30041Z | Other | PROVIDER IDENTIFICATION # |
CA | RN518440 | Other | MEDICAL PROVIDER RENDERIN |