Provider Demographics
NPI:1639229867
Name:LILLIE, KRISTIN (AUD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:LILLIE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:ANDERLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2743 FAIRWAY ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-7706
Mailing Address - Country:US
Mailing Address - Phone:503-982-0261
Mailing Address - Fax:
Practice Address - Street 1:2611 PRINGLE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1533
Practice Address - Country:US
Practice Address - Phone:503-588-5330
Practice Address - Fax:503-540-4473
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22536237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234462Medicaid