Provider Demographics
NPI:1568828994
Name:LILLEBERG, DARLA
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:
Last Name:LILLEBERG
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 1:428 E 4TH ST
Mailing Address - Street 2:SUITE 333
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2434
Mailing Address - Country:US
Mailing Address - Phone:980-819-1329
Mailing Address - Fax:
Practice Address - Street 1:428 E 4TH ST
Practice Address - Street 2:SUITE 333
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2434
Practice Address - Country:US
Practice Address - Phone:980-819-1329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC753135174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist