Provider Demographics
NPI:1811604473
Name:LILLY, AUDRA BETH (CPNP-PC)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:BETH
Last Name:LILLY
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7389 W GRANT RANCH BLVD APT 1422
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80123-2671
Mailing Address - Country:US
Mailing Address - Phone:214-789-4855
Mailing Address - Fax:
Practice Address - Street 1:4900 E KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-2365
Practice Address - Country:US
Practice Address - Phone:303-756-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0997726363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty