Provider Demographics
NPI:1508375544
Name:LILLY, AMY L
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:LILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:DOENITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR STE J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:990 W ANN ARBOR TRL STE 210
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6202
Practice Address - Country:US
Practice Address - Phone:734-455-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285512363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics