Provider Demographics
NPI:1982932240
Name:LILLY, JENIENE CHARMAINE (LICENSED PRACTICAL N)
Entity Type:Individual
Prefix:MS
First Name:JENIENE
Middle Name:CHARMAINE
Last Name:LILLY
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 GRANT AVE (BETWEEN 164 & 165TH ST.)
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456
Mailing Address - Country:US
Mailing Address - Phone:718-537-3190
Mailing Address - Fax:
Practice Address - Street 1:2505 TILDEN AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226
Practice Address - Country:US
Practice Address - Phone:718-941-4490
Practice Address - Fax:718-703-1716
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095390-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse