Provider Demographics
NPI:1952836298
Name:LILLY-BERNAU, KIM N (AGNP-C)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:N
Last Name:LILLY-BERNAU
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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:941-279-3145
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704294325363LG0600X
FLAPRN11019249363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology