Basic Information
| Provider Information | |||||||||
| NPI: | 1992971253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LILLY | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042543131 | ||||||||
| FaxNumber: | 3042543172 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 12TH STREET EXT | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877275 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2008 | ||||||||
| LastUpdateDate: | 10/20/2017 | ||||||||
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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 | 363A00000X | 733 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 463 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.