Basic Information
| Provider Information | |||||||||
| NPI: | 1699736231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HILLIARD | ||||||||
| FirstName: | LORIE | ||||||||
| MiddleName: | O'CONNOR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRADLEY | ||||||||
| OtherFirstName: | LORIE | ||||||||
| OtherMiddleName: | O'CONNOR | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | STE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453107 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 618 HOSPITAL RD | ||||||||
| Address2: | DEPARTMENT OF ANESTHESIA | ||||||||
| City: | TAPPAHANNOCK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 225605000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044433311 | ||||||||
| FaxNumber: | 7032959369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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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 | 367500000X | 0024116011 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 181126816 | 05 | VA | MEDICAID | 1699736231 | 05 | VA | MEDICAID |