Healthcare Provider Details

I. General information

NPI: 1972966992
Provider Name (Legal Business Name): JEANNETTE RENEE LILLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S UNION BLVD STE 300
COLORADO SPRINGS CO
80910-3126
US

IV. Provider business mailing address

335 DISCOVERY CT
COLORADO SPRINGS CO
80919-1213
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-7630
  • Fax: 719-365-7631
Mailing address:
  • Phone: 719-231-4579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1617166
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0992352
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: