Basic Information
| Provider Information | |||||||||
| NPI: | 1659024347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LILLY | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26005 RIDGE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208721899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014142300 | ||||||||
| FaxNumber: | 3014140476 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 TAVERN RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254012890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042634999 | ||||||||
| FaxNumber: | 3042630984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2022 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | AC004114 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 93424 | 01 | WV | WV BOARD OF NURSING | OTHER |