Provider Demographics
NPI:1770590127
Name:LILJA, JUDITH ANN (NP)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANN
Last Name:LILJA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 S CYPRESS BEND DR
Mailing Address - Street 2:APT 102
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-4452
Mailing Address - Country:US
Mailing Address - Phone:954-972-1087
Mailing Address - Fax:
Practice Address - Street 1:6931 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33313-4406
Practice Address - Country:US
Practice Address - Phone:954-583-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3196012363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00011954OtherRR MEDICARE
FLP00011953OtherRR MEDICARE
FLY028HOtherBLUE SHIELD
S24878Medicare UPIN
FLY028HOtherBLUE SHIELD
FLP00011954OtherRR MEDICARE