Provider Demographics
NPI:1932100096
Name:LILLIE, JESSICA MARIE (APNP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:LILLIE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 W AMERICAN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1405
Mailing Address - Country:US
Mailing Address - Phone:920-722-7747
Mailing Address - Fax:
Practice Address - Street 1:1265 W AMERICAN DR STE 100
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-722-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2472-033363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932100096Medicaid
WI12073004Medicare PIN
WI12074004Medicare PIN
WI12072004Medicare PIN
WIQ30406Medicare UPIN