Healthcare Provider Details

I. General information

NPI: 1346510716
Provider Name (Legal Business Name): JOHN WAYNE LILLY JR. APRN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN WAYNE LILLY APRN, FNP-BC

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N. EISENHOWER DR.
BECKLEY WV
25801-3140
US

IV. Provider business mailing address

330 N EISENHOWER DR
BECKLEY WV
25801-4141
US

V. Phone/Fax

Practice location:
  • Phone: 304-929-0786
  • Fax: 304-929-2278
Mailing address:
  • Phone: 304-929-0786
  • Fax: 304-929-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number64742
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: