Provider Demographics
NPI:1558382358
Name:DUBARD, LILLIAN LORRAINE (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:LILLIAN
Middle Name:LORRAINE
Last Name:DUBARD
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:LILLIAN
Other - Middle Name:LORRAINE
Other - Last Name:CASIDAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:965 AVENT DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5045
Mailing Address - Country:US
Mailing Address - Phone:662-227-7575
Mailing Address - Fax:662-227-6575
Practice Address - Street 1:965 AVENT DR
Practice Address - Street 2:SUITE 107
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-7575
Practice Address - Fax:662-227-6575
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR713066363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02654890Medicaid
MS02654890Medicaid
MS500001641Medicare PIN