Provider Demographics
NPI:1932619319
Name:LILLY, ALLEGRA DANIELLE ANDERSON (CPM, LDM)
Entity Type:Individual
Prefix:
First Name:ALLEGRA
Middle Name:DANIELLE ANDERSON
Last Name:LILLY
Suffix:
Gender:F
Credentials:CPM, LDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9156 SW SUNDOWN CANYON RD
Mailing Address - Street 2:
Mailing Address - City:TERREBONNE
Mailing Address - State:OR
Mailing Address - Zip Code:97760-9377
Mailing Address - Country:US
Mailing Address - Phone:503-860-6361
Mailing Address - Fax:
Practice Address - Street 1:19800 VILLAGE OFFICE CT STE 105
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1813
Practice Address - Country:US
Practice Address - Phone:541-647-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17100004176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN17100004OtherNARM