MEDICARE: JENNIFER DIANE LILES APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	A004988	AR

General Provider Information

NPI Number	:	1174069611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DIANE LILES APRN

Provider Business Mailing Address
First Line	:	600 MEMORIAL DR
Second Line	:
City	:	BELLA VISTA
State	:	AR
Zip	:	72714-1847
Country	:	US
Telephone Number	:	479-855-6165
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 MEMORIAL DR
Second Line	:
City	:	BELLA VISTA
State	:	AR
Zip	:	72714-1847
Country	:	US
Telephone Number	:	479-855-6165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2017
Last Update Date	:	01/09/2017

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