Healthcare Provider Details

I. General information

NPI: 1467683904
Provider Name (Legal Business Name): LILY KRISTINE SUNIO M.D,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 PARK PL
MISHAWAKA IN
46545-3519
US

IV. Provider business mailing address

PO BOX 5909
PORTLAND OR
97228-5909
US

V. Phone/Fax

Practice location:
  • Phone: 574-273-6767
  • Fax: 574-273-6757
Mailing address:
  • Phone: 574-273-6767
  • Fax: 574-968-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301094169
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01073784A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01073784A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: