Provider Demographics
NPI:1205449592
Name:LILLY, ANTHONY N
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:N
Last Name:LILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9227 ELLISON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JUMPING BRANCH
Mailing Address - State:WV
Mailing Address - Zip Code:25969-6097
Mailing Address - Country:US
Mailing Address - Phone:304-466-4237
Mailing Address - Fax:
Practice Address - Street 1:9227 ELLISON RIDGE RD
Practice Address - Street 2:
Practice Address - City:JUMPING BRANCH
Practice Address - State:WV
Practice Address - Zip Code:25969-6097
Practice Address - Country:US
Practice Address - Phone:304-466-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant