Healthcare Provider Details

I. General information

NPI: 1669397998
Provider Name (Legal Business Name): LILLIE NELSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23000 MOAKLEY ST STE 102
LEONARDTOWN MD
20650-2916
US

IV. Provider business mailing address

23000 MOAKLEY ST STE 102
LEONARDTOWN MD
20650-2916
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-5555
  • Fax: 301-475-8535
Mailing address:
  • Phone:
  • Fax: 301-475-8535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6239
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: