Provider Demographics
NPI:1669992830
Name:LILLY, MARY KATHRYN (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:LILLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 TEMPLEMORE DR
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-4800
Mailing Address - Country:US
Mailing Address - Phone:850-450-3942
Mailing Address - Fax:
Practice Address - Street 1:5041 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8916
Practice Address - Country:US
Practice Address - Phone:850-433-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174962363LF0000X
FL2718922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily