Provider Demographics
NPI:1679044507
Name:CARTER, LILLIAN MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:MARIE
Last Name:CARTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:LILLIAN
Other - Middle Name:MARIE
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:22097 PIPER AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2412
Mailing Address - Country:US
Mailing Address - Phone:313-854-6079
Mailing Address - Fax:
Practice Address - Street 1:22097 PIPER AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2412
Practice Address - Country:US
Practice Address - Phone:313-854-6079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703113828164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI611755491Medicaid