Healthcare Provider Details

I. General information

NPI: 1689385494
Provider Name (Legal Business Name): LILLIAN KAVISHE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 JONES BRIDGE RD
BETHESDA MD
20814-4799
US

IV. Provider business mailing address

311 S TRIMBLE RD
MANSFIELD OH
44906-2997
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-9004
  • Fax:
Mailing address:
  • Phone: 614-390-9445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number378629
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: