Provider Demographics
NPI:1518736362
Name:DONNELLY, LILLIAN B
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:B
Last Name:DONNELLY
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 1:4542 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1040
Mailing Address - Country:US
Mailing Address - Phone:517-764-1202
Mailing Address - Fax:517-782-0052
Practice Address - Street 1:4542 PAGE AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1040
Practice Address - Country:US
Practice Address - Phone:517-764-1202
Practice Address - Fax:517-782-0052
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
MI4704254121163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No163W00000XNursing Service ProvidersRegistered Nurse