Provider Demographics
NPI:1356091417
Name:DUAN, LILY
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:DUAN
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 1:2831 WILLOWSTONE DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4013
Mailing Address - Country:US
Mailing Address - Phone:718-885-6880
Mailing Address - Fax:
Practice Address - Street 1:10900 MEDLOCK BRIDGE RD STE 101A
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1505
Practice Address - Country:US
Practice Address - Phone:470-628-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009921225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT009921OtherMASSAGE THERAPIST