Provider Demographics
NPI:1952450926
Name:LILLY, CARIANNE NICOLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:CARIANNE
Middle Name:NICOLE
Last Name:LILLY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 TRINITY PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-5006
Mailing Address - Country:US
Mailing Address - Phone:773-547-3065
Mailing Address - Fax:
Practice Address - Street 1:1540 TRINITY PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5006
Practice Address - Country:US
Practice Address - Phone:574-272-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005276213E00000X
390200000X
PASC006327213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program