Healthcare Provider Details

I. General information

NPI: 1366134017
Provider Name (Legal Business Name): LILLY KATHERINE DEERIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE RD STE S207
BETHESDA MD
20816-2529
US

IV. Provider business mailing address

1323 11TH ST NW
WASHINGTON DC
20001-4219
US

V. Phone/Fax

Practice location:
  • Phone: 202-684-7167
  • Fax:
Mailing address:
  • Phone: 202-997-2613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1053277
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR257937
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: