Provider Demographics
NPI:1104584259
Name:LILLY, VICTORIA ROSE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROSE
Last Name:LILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N CENTRAL EXPY STE 409
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5311
Mailing Address - Country:US
Mailing Address - Phone:214-838-8237
Mailing Address - Fax:855-566-0474
Practice Address - Street 1:680 MIX AVE APT 4C
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-2341
Practice Address - Country:US
Practice Address - Phone:765-686-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002008133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered