Provider Demographics
NPI:1437809332
Name:LILLY, KATHLEEN ANN (APRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:LILLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2317
Mailing Address - Country:US
Mailing Address - Phone:313-224-2247
Mailing Address - Fax:
Practice Address - Street 1:525 CLINTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2317
Practice Address - Country:US
Practice Address - Phone:313-224-2247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-180664163W00000X
MI4704406562363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty