Provider Demographics
NPI:1467797936
Name:LILEY, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:LILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 E. I80 SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009
Mailing Address - Country:US
Mailing Address - Phone:307-274-2646
Mailing Address - Fax:
Practice Address - Street 1:3304 E. I80 SERVICE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009
Practice Address - Country:US
Practice Address - Phone:307-274-2646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker