Provider Demographics
NPI:1497139869
Name:MA-PEREZ, LILLY (CPNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:LILLY
Middle Name:
Last Name:MA-PEREZ
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:MS
Other - First Name:LILLY
Other - Middle Name:
Other - Last Name:MA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-PC
Mailing Address - Street 1:180 E PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1915
Mailing Address - Country:US
Mailing Address - Phone:631-425-3811
Mailing Address - Fax:
Practice Address - Street 1:180 E PULASKI RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1915
Practice Address - Country:US
Practice Address - Phone:631-425-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY655723163W00000X
NYF382604363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse