Basic Information
| Provider Information | |||||||||
| NPI: | 1093225815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LILLICO | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 628 WOODSTREAM DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633047971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362558090 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9556 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149612255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2017 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2017024415 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 71007531A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.