Provider Demographics
NPI:1619320306
Name:LILLY, SHUNTINA LENETTE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SHUNTINA
Middle Name:LENETTE
Last Name:LILLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3394 COOPER BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2321
Mailing Address - Country:US
Mailing Address - Phone:706-405-6980
Mailing Address - Fax:
Practice Address - Street 1:5710 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9004
Practice Address - Country:US
Practice Address - Phone:706-256-6247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN186067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily