Healthcare Provider Details

I. General information

NPI: 1669992830
Provider Name (Legal Business Name): MARY KATHRYN LILLY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5041 N 12TH AVE
PENSACOLA FL
32504-8916
US

IV. Provider business mailing address

1523 TEMPLEMORE DR
CANTONMENT FL
32533-4800
US

V. Phone/Fax

Practice location:
  • Phone: 850-433-2155
  • Fax:
Mailing address:
  • Phone: 850-450-3942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174962
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2718922
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: