Provider Demographics
NPI:1376783993
Name:LILLARD, NINA DANTZLER (PMHCNS-BC)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:DANTZLER
Last Name:LILLARD
Suffix:
Gender:F
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3877
Mailing Address - Country:US
Mailing Address - Phone:828-327-6633
Mailing Address - Fax:828-327-3385
Practice Address - Street 1:858 2ND ST NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3877
Practice Address - Country:US
Practice Address - Phone:828-327-6633
Practice Address - Fax:828-327-3385
Is Sole Proprietor?:No
Enumeration Date:2009-02-22
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99155364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6004039Medicaid
NCP31788Medicare UPIN