Basic Information
| Provider Information | |||||||||
| NPI: | 1811030091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DILLON | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | F.N.P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 ENOCHS ST | ||||||||
| Address2: | |||||||||
| City: | TYLERTOWN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396672711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018763858 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 ENOCHS ST | ||||||||
| Address2: | |||||||||
| City: | TYLERTOWN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396672711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018763858 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R831743 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00120305 | 05 | MS | MEDICAID |