Provider Demographics
NPI:1831243849
Name:LILLY, ALICE J (WHNP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:J
Last Name:LILLY
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:761 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:770-513-4000
Mailing Address - Fax:770-995-3495
Practice Address - Street 1:761 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:770-513-4000
Practice Address - Fax:770-995-3495
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN092698363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00843752BMedicaid
GA000843752BOtherPEACH STATE
GA00843752BOtherWELLCARE