Provider Demographics
NPI:1821797622
Name:EHEALTH PROVISIONS, LLC
Entity Type:Organization
Organization Name:EHEALTH PROVISIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:NGUYET
Authorized Official - Last Name:LILLY-BERNAU
Authorized Official - Suffix:
Authorized Official - Credentials:AGPCNP-C
Authorized Official - Phone:313-720-3358
Mailing Address - Street 1:54359 ALGONQUIN DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-1106
Mailing Address - Country:US
Mailing Address - Phone:313-720-3358
Mailing Address - Fax:
Practice Address - Street 1:1435 S OSPREY AVE STE 200
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2905
Practice Address - Country:US
Practice Address - Phone:941-404-5453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty