Healthcare Provider Details

I. General information

NPI: 1932619319
Provider Name (Legal Business Name): ALLEGRA DANIELLE ANDERSON LILLY CPM, LDM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19800 VILLAGE OFFICE CT STE 105
BEND OR
97702-1813
US

IV. Provider business mailing address

9156 SW SUNDOWN CANYON RD
TERREBONNE OR
97760-9377
US

V. Phone/Fax

Practice location:
  • Phone: 541-647-1788
  • Fax:
Mailing address:
  • Phone: 503-860-6361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number17100004
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier17100004
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerNARM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: