Provider Demographics
NPI:1851381172
Name:LILLY, ROSE MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:MARIE
Last Name:LILLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HOLLOWAY DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5695
Mailing Address - Country:US
Mailing Address - Phone:757-262-0268
Mailing Address - Fax:757-314-7703
Practice Address - Street 1:30 HOLLOWAY DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5695
Practice Address - Country:US
Practice Address - Phone:757-314-7715
Practice Address - Fax:757-314-7703
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1101452363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAD000Medicare UPIN