Healthcare Provider Details

I. General information

NPI: 1891124103
Provider Name (Legal Business Name): JAMIE LILLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1734 JOHN SMALL AVE
WASHINGTON NC
27889-7387
US

IV. Provider business mailing address

1734 JOHN SMALL AVE
WASHINGTON NC
27889-7387
US

V. Phone/Fax

Practice location:
  • Phone: 252-561-5560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number7510
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: