Basic Information
| Provider Information | |||||||||
| NPI: | 1649388349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | LILLIE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 959 LAKE HARBOUR DR | ||||||||
| Address2: | #502 | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391571067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013683904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | MH CONSULT TEAM A342 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013683904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363A00000X | 1013986 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.