Healthcare Provider Details

I. General information

NPI: 1932929429
Provider Name (Legal Business Name): STEPHANIE LILLEY IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE OF THE WOODS RD
COLUMBIA MO
65202-6936
US

IV. Provider business mailing address

2350 N LAKE OF THE WOODS RD
COLUMBIA MO
65202-6936
US

V. Phone/Fax

Practice location:
  • Phone: 573-310-9318
  • Fax:
Mailing address:
  • Phone: 573-310-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-68015
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: