Basic Information
| Provider Information | |||||||||
| NPI: | 1467043026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DILLARD | ||||||||
| FirstName: | FELICIA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | DNP, AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 6019 WALNUT GROVE RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012264910 | ||||||||
| FaxNumber: | 9012264915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2021 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 904542 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 29093 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.