Provider Demographics
NPI:1972108280
Name:SHIVELY, LILLIAN G (PA-C)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:G
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LILLIAN
Other - Middle Name:G
Other - Last Name:TEPEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:390 MAPLE SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2000
Mailing Address - Country:US
Mailing Address - Phone:618-498-7518
Mailing Address - Fax:618-498-3052
Practice Address - Street 1:270 MAPLE SUMMIT RD
Practice Address - Street 2:MCDOW BLDG
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052
Practice Address - Country:US
Practice Address - Phone:618-498-7108
Practice Address - Fax:618-498-7919
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant