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General NPI Number Information
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NPI Number | 1245606961
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Entity Type | Individual
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Provider Name | ANNE MARIE LILLYBLAD FNP
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Gender | Female
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Dates
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Enumeration Date | 08/17/2015
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Last Update Date | 03/11/2021
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Provider Practice Location Address
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Address Line | 10705 TOWN SQUARE DR NE STE 100
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City | BLAINE
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State | MN
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Zip | 55449-8184
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Country | US
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Telephone | 763-236-5400
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Fax |
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Provider Business Mailing Address
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Address Line | 4457 118TH AVE NE
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City | BLAINE
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State | MN
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Zip | 55449-5857
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Country | US
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Telephone | 763-228-3549
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | R174346-3
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | CNP 4008
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License Number State | MN
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