Provider Demographics
NPI:1821221920
Name:LILLY, MARY L (PHD RN MS MSN)
Entity Type:Individual
Prefix:PROF
First Name:MARY
Middle Name:L
Last Name:LILLY
Suffix:
Gender:F
Credentials:PHD RN MS MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 NORTH PIEDRAS
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930
Mailing Address - Country:US
Mailing Address - Phone:915-564-6100
Mailing Address - Fax:
Practice Address - Street 1:4715 VIEWRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN169742363LA2200X
IN70000096A364SP0809X
TX760860364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health