Provider Demographics
NPI:1336599091
Name:DEVITO, LILLIAN (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:DEVITO
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-786-6460
Mailing Address - Fax:954-786-7304
Practice Address - Street 1:201 E SAMPLE RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-3502
Practice Address - Country:US
Practice Address - Phone:954-786-6460
Practice Address - Fax:954-786-7304
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289794363LA2200X
MN6759363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110743200Medicaid