Provider Demographics
NPI:1932887056
Name:WHITLEY, LILLY DAWN
Entity Type:Individual
Prefix:
First Name:LILLY
Middle Name:DAWN
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 WOODWIND CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-6881
Mailing Address - Country:US
Mailing Address - Phone:502-558-7054
Mailing Address - Fax:
Practice Address - Street 1:163 WOODWIND CT
Practice Address - Street 2:
Practice Address - City:MOUNT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-6881
Practice Address - Country:US
Practice Address - Phone:502-558-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY286886133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered