Provider Demographics
NPI:1659024347
Name:LILLY, BREANNA NICOLE (CNM)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICOLE
Last Name:LILLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:26005 RIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-1899
Mailing Address - Country:US
Mailing Address - Phone:301-414-2300
Mailing Address - Fax:301-414-0476
Practice Address - Street 1:99 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2890
Practice Address - Country:US
Practice Address - Phone:304-263-4999
Practice Address - Fax:304-263-0984
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-08-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDAC004114367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV93424OtherWV BOARD OF NURSING