Healthcare Provider Details

I. General information

NPI: 1841555281
Provider Name (Legal Business Name): KELLY LYNN LILLIE RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N MAIN ST
BUFFALO CENTER IA
50424-7731
US

IV. Provider business mailing address

621 S ILLINOIS AVE STE 103
MASON CITY IA
50401-5489
US

V. Phone/Fax

Practice location:
  • Phone: 507-238-4949
  • Fax: 507-238-4949
Mailing address:
  • Phone: 641-428-3041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR2065946
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA078331
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: