Healthcare Provider Details

I. General information

NPI: 1376320143
Provider Name (Legal Business Name): LILY NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N NORMA ST STE 125
RIDGECREST CA
93555-2577
US

IV. Provider business mailing address

1400 N NORMA ST STE 125
RIDGECREST CA
93555-2577
US

V. Phone/Fax

Practice location:
  • Phone: 760-499-7406
  • Fax: 760-499-9259
Mailing address:
  • Phone: 760-499-7406
  • Fax: 760-499-9259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: