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General NPI Number Information
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NPI Number | 1932990306
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Entity Type | Individual
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Provider Name | MISTY ROSE LILES
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Gender | Female
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Dates
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Enumeration Date | 05/15/2025
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Last Update Date | 05/15/2025
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Provider Practice Location Address
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Address Line | 2503 W MAIN ST STE 2
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-2532
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Country | US
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Telephone | 479-219-1219
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Fax | 479-339-8760
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Provider Business Mailing Address
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Address Line | PO BOX 2109
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City | RUSSELLVILLE
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State | AR
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Zip | 72811-2109
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Country | US
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Telephone | 479-967-2322
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Fax | 479-339-8760
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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