Provider Demographics
NPI:1316432578
Name:PHAN, LILY NGOC
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:NGOC
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LILY
Other - Middle Name:NGOC
Other - Last Name:HO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1240 EAGLES LANDING PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5173
Mailing Address - Country:US
Mailing Address - Phone:770-389-3855
Mailing Address - Fax:770-474-8078
Practice Address - Street 1:1240 EAGLES LANDING PKWY STE 110
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5173
Practice Address - Country:US
Practice Address - Phone:770-389-3855
Practice Address - Fax:770-474-8078
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN247909363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily