Provider Demographics
NPI:1245606961
Name:LILLYBLAD, ANNE MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:LILLYBLAD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4457 118TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5857
Mailing Address - Country:US
Mailing Address - Phone:763-228-3549
Mailing Address - Fax:
Practice Address - Street 1:10705 TOWN SQUARE DR NE
Practice Address - Street 2:STE 100
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-8184
Practice Address - Country:US
Practice Address - Phone:763-236-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR174346-3163W00000X
MNCNP 4008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse