Provider Demographics
NPI:1306655329
Name:LILLY, TONI (RN)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:LILLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 CRYSTAL PALACE CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-2256
Mailing Address - Country:US
Mailing Address - Phone:443-804-2294
Mailing Address - Fax:
Practice Address - Street 1:6340 SECURITY BLVD STE 100B8
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-5173
Practice Address - Country:US
Practice Address - Phone:443-804-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD376K00000X
MDR213894163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD210590000Medicaid