Provider Demographics
NPI:1396047304
Name:LILLIE, LASHUNE GAIL
Entity type:Individual
Prefix:
First Name:LASHUNE
Middle Name:GAIL
Last Name:LILLIE
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 1:5430 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34482-5589
Mailing Address - Country:US
Mailing Address - Phone:352-484-6064
Mailing Address - Fax:
Practice Address - Street 1:5430 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34482-5589
Practice Address - Country:US
Practice Address - Phone:352-484-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000730300Medicaid