Provider Demographics
NPI:1487475075
Name:LEVINE, LILY ANNA (RN, PMHNP)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:ANNA
Last Name:LEVINE
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:LILY
Other - Middle Name:ANNA
Other - Last Name:ROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4228 CORINTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6021
Mailing Address - Country:US
Mailing Address - Phone:310-770-6722
Mailing Address - Fax:
Practice Address - Street 1:2516 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-5043
Practice Address - Country:US
Practice Address - Phone:310-770-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA780940163W00000X
CA95032624363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse