Provider Demographics
NPI:1790547313
Name:WALDEN LILLY LLC
Entity Type:Organization
Organization Name:WALDEN LILLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNPBC, FNPBC
Authorized Official - Phone:304-731-5195
Mailing Address - Street 1:1702 CONSERVATION TRL UNIT 104
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-5087
Mailing Address - Country:US
Mailing Address - Phone:304-731-5195
Mailing Address - Fax:
Practice Address - Street 1:1702 CONSERVATION TRL UNIT 104
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-5087
Practice Address - Country:US
Practice Address - Phone:304-731-5195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty