Healthcare Provider Details

I. General information

NPI: 1154905065
Provider Name (Legal Business Name): LILLY KEMM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 PARK AVE # WP1-200
TRUMBULL CT
06611-3463
US

IV. Provider business mailing address

665 COMMERCE DR APT 324
FAIRFIELD CT
06825-5568
US

V. Phone/Fax

Practice location:
  • Phone: 203-666-3750
  • Fax:
Mailing address:
  • Phone: 732-859-8193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12273
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number155744
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: