Provider Demographics
NPI:1346510716
Name:LILLY, JOHN WAYNE JR (APRN, FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WAYNE
Last Name:LILLY
Suffix:JR
Gender:M
Credentials:APRN, FNP-BC
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:WAYNE
Other - Last Name:LILLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN, FNP-BC
Mailing Address - Street 1:330 N EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4141
Mailing Address - Country:US
Mailing Address - Phone:304-929-0786
Mailing Address - Fax:304-929-2278
Practice Address - Street 1:330 N. EISENHOWER DR.
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3140
Practice Address - Country:US
Practice Address - Phone:304-929-0786
Practice Address - Fax:304-929-2278
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV64742363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily