Provider Demographics
NPI:1174855183
Name:LILLJEDAHL, AMYE SUZETTE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMYE
Middle Name:SUZETTE
Last Name:LILLJEDAHL
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:235 W PALM ST STE 105
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77418-1300
Mailing Address - Country:US
Mailing Address - Phone:979-865-3124
Mailing Address - Fax:979-865-9193
Practice Address - Street 1:235 W PALM ST STE 105
Practice Address - Street 2:
Practice Address - City:BELLVILLE
Practice Address - State:TX
Practice Address - Zip Code:77418-1300
Practice Address - Country:US
Practice Address - Phone:979-865-3124
Practice Address - Fax:979-865-9193
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA01100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant