Provider Demographics
NPI:1841555281
Name:LILLIE, KELLY LYNN (RN, CNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:LILLIE
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-428-3041
Mailing Address - Fax:
Practice Address - Street 1:2440 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2088
Practice Address - Country:US
Practice Address - Phone:507-320-7900
Practice Address - Fax:507-320-7900
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR2065946363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN500007971Medicare PIN