Provider Demographics
NPI:1376392506
Name:LILLIS, CHEYENNE SUMMER (MAT, LAT, ATC, NREMT)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:SUMMER
Last Name:LILLIS
Suffix:
Gender:F
Credentials:MAT, LAT, ATC, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 E IDAHO AVE UNIT 319B
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6165 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8613
Practice Address - Country:US
Practice Address - Phone:208-302-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program