Provider Demographics
NPI:1023231081
Name:LILLEY, KATHLEEN A (RD CDE)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:LILLEY
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4604
Mailing Address - Country:US
Mailing Address - Phone:425-688-5484
Mailing Address - Fax:425-688-5281
Practice Address - Street 1:1120 112TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4500
Practice Address - Country:US
Practice Address - Phone:425-688-5484
Practice Address - Fax:424-688-5281
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
414992133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP58839Medicare UPIN