Provider Demographics
NPI:1053893792
Name:LILJESTROM, ALLISON BRYNNE (MAED)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:BRYNNE
Last Name:LILJESTROM
Suffix:
Gender:F
Credentials:MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6362
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-6362
Mailing Address - Country:US
Mailing Address - Phone:307-730-9262
Mailing Address - Fax:
Practice Address - Street 1:355 ARAPAHOE LN
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8607
Practice Address - Country:US
Practice Address - Phone:307-730-9262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator