Provider Demographics
NPI:1285101592
Name:LILLY, STEPHANIE (CRNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LILLY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:GLECO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3901 BEAR CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAR CREEK TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18702-9752
Mailing Address - Country:US
Mailing Address - Phone:570-574-4611
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAR CREEK BLVD
Practice Address - Street 2:
Practice Address - City:BEAR CREEK TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18702-9752
Practice Address - Country:US
Practice Address - Phone:570-574-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN587980163W00000X
PASP019836363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103612815-0001Medicaid