Provider Demographics
NPI:1225313943
Name:LILIE, JAMIE ANN (CRNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:ANN
Last Name:LILIE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:MESSINO
Other - Last Name:LILIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MERLINI DR STE 2A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:PA
Mailing Address - Zip Code:17512-9706
Mailing Address - Country:US
Mailing Address - Phone:717-684-3663
Mailing Address - Fax:
Practice Address - Street 1:19875 SW 65TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8353
Practice Address - Country:US
Practice Address - Phone:503-692-7785
Practice Address - Fax:503-692-2520
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011666363LA2200X
OR201908210NP-PP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103289908Medicaid