Provider Demographics
NPI:1396865929
Name:LILLICO, MARY P (RD LD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:P
Last Name:LILLICO
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5413 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79108-4607
Mailing Address - Country:US
Mailing Address - Phone:806-381-4322
Mailing Address - Fax:806-381-4322
Practice Address - Street 1:5413 RIVER RD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79108-4607
Practice Address - Country:US
Practice Address - Phone:806-381-4322
Practice Address - Fax:806-381-4322
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02437133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K8622OtherLINK TO 00BF18