Provider Demographics
NPI:1205296258
Name:LILLY, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 BEACON AVE
Mailing Address - Street 2:
Mailing Address - City:PAULSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08066-1155
Mailing Address - Country:US
Mailing Address - Phone:609-847-4050
Mailing Address - Fax:
Practice Address - Street 1:2704 WALNUT RIDGE EST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-3094
Practice Address - Country:US
Practice Address - Phone:856-443-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ163WH0200X251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health