Provider Demographics
NPI:1346929601
Name:PARK, LILLY H (NP)
Entity Type:Individual
Prefix:MS
First Name:LILLY
Middle Name:H
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16127 BENT GRASS DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-4615
Mailing Address - Country:US
Mailing Address - Phone:708-253-5020
Mailing Address - Fax:
Practice Address - Street 1:10604 SOUTHWEST HWY STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2717
Practice Address - Country:US
Practice Address - Phone:708-424-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027841363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner