Provider Demographics
NPI:1972966992
Name:LILLER, JEANNETTE RENEE (NP)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:RENEE
Last Name:LILLER
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 1:335 DISCOVERY CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1213
Mailing Address - Country:US
Mailing Address - Phone:719-231-4579
Mailing Address - Fax:
Practice Address - Street 1:175 S UNION BLVD STE 300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3126
Practice Address - Country:US
Practice Address - Phone:719-365-7630
Practice Address - Fax:719-365-7631
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1617166163W00000X
CO0992352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF0316328OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS
CO0992352OtherAPN
CO1617166OtherREGISTERED NURSE LICENSE