Basic Information
| Provider Information | |||||||||
| NPI: | 1841593159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LILLY | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6126 TWIGGS CT | ||||||||
| Address2: | |||||||||
| City: | HOPE MILLS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283489036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106447596 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5841 HWY. 421 S. | ||||||||
| Address2: | |||||||||
| City: | BUIES CREEK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275060457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108935727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2010 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P015187 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.