Healthcare Provider Details

I. General information

NPI: 1417588773
Provider Name (Legal Business Name): JESSE LILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VERMILLION ST
ATHENS WV
24712-9027
US

IV. Provider business mailing address

251 SAMARITAN DR
SHADY SPRING WV
25918-8231
US

V. Phone/Fax

Practice location:
  • Phone: 304-322-6264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 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: