Provider Demographics
NPI:1346797040
Name:LILLEY, LEAH (PA-C)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:LILLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11277 VERNON PL STE 200
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3719
Mailing Address - Country:US
Mailing Address - Phone:814-724-1252
Mailing Address - Fax:814-333-8871
Practice Address - Street 1:11277 VERNON PL STE 200
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3719
Practice Address - Country:US
Practice Address - Phone:814-724-1252
Practice Address - Fax:814-333-8871
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
PAMA060793363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program