Provider Demographics
NPI:1770636946
Name:LILLY, HAROLETTA MARIE (RNC WHNP)
Entity Type:Individual
Prefix:
First Name:HAROLETTA
Middle Name:MARIE
Last Name:LILLY
Suffix:
Gender:F
Credentials:RNC WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G3371 BEECHER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3621
Mailing Address - Country:US
Mailing Address - Phone:810-238-3631
Mailing Address - Fax:810-234-5956
Practice Address - Street 1:G3371 BEECHER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3621
Practice Address - Country:US
Practice Address - Phone:810-238-3631
Practice Address - Fax:810-238-3631
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704169927363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008753530OtherBLUE CROSS BLUE SHIELD
MIM37240007Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MIS39105Medicare UPIN