Basic Information
| Provider Information | |||||||||
| NPI: | 1841555281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LILLIE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S ILLINOIS AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504015489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414283041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 635 E US HIGHWAY 9 | ||||||||
| Address2: | |||||||||
| City: | FOREST CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504361028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6415852904 | ||||||||
| FaxNumber: | 6414284997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R2065946 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | MN | MEDICAID |