Provider Demographics
NPI:1417905340
Name:QUILLAN, LYNN D (NP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:D
Last Name:QUILLAN
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8614
Mailing Address - Fax:
Practice Address - Street 1:1120 GROVE RD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4656
Practice Address - Country:US
Practice Address - Phone:864-455-6444
Practice Address - Fax:864-455-6598
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2392363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0083Medicaid
SCP197363640Medicare PIN
SCP197367951Medicare PIN
SCNP0083Medicaid