Provider Demographics
NPI:1700100146
Name:LILLEY, LARRY LEE III (NNP)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:LILLEY
Suffix:III
Gender:M
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 ARAGONA DR
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-2807
Mailing Address - Country:US
Mailing Address - Phone:540-342-1004
Mailing Address - Fax:
Practice Address - Street 1:627 ARAGONA DR
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2807
Practice Address - Country:US
Practice Address - Phone:540-342-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-14
Last Update Date:2010-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001190201163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care