Provider Demographics
NPI:1164501177
Name:DECILLIS, LYNNETTE A
Entity type:Individual
Prefix:MS
First Name:LYNNETTE
Middle Name:A
Last Name:DECILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LYNNETTE
Other - Middle Name:A
Other - Last Name:WILLEMAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2350 GEARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3305
Mailing Address - Country:US
Mailing Address - Phone:415-833-4356
Mailing Address - Fax:
Practice Address - Street 1:2350 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3305
Practice Address - Country:US
Practice Address - Phone:415-833-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 13102363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN518440OtherMEDICAL PROVIDER RENDERIN
CA(PIN):ZZZ30041ZOtherPROVIDER IDENTIFICATION #
CARN518440OtherMEDICAL PROVIDER RENDERIN