Provider Demographics
NPI:1679392930
Name:LILLY, DESTINY DAWN
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:DAWN
Last Name:LILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:DAWN
Other - Last Name:LILLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:355 BLUEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-2883
Mailing Address - Country:US
Mailing Address - Phone:304-425-7111
Mailing Address - Fax:304-425-1138
Practice Address - Street 1:600 TRENT STREET
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-425-7111
Practice Address - Fax:304-425-1138
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15687960273747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant