Provider Demographics
NPI:1760734677
Name:LILLY, HEATHER (NMD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:LILLY
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 E. JACKSON ST.
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-770-5563
Mailing Address - Fax:541-772-3028
Practice Address - Street 1:1012 E. JACKSON ST.
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-770-5563
Practice Address - Fax:541-772-3028
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12-1325175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath