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General NPI Number Information
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NPI Number | 1669951455
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Entity Type | Individual
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Provider Name | LILLIOT PHILLIPS AG-ACNP
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Gender | Male
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Dates
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Enumeration Date | 08/13/2018
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Last Update Date | 02/15/2021
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Provider Practice Location Address
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Address Line | 54123 LISA DR
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City | CALLAHAN
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State | FL
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Zip | 32011-5989
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Country | US
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Telephone | 904-955-3062
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Fax |
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Provider Business Mailing Address
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Address Line | 54123 LISA DR
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City | CALLAHAN
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State | FL
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Zip | 32011-5989
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Country | US
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Telephone | 904-955-3062
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APRN1617712
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License Number State | FL
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