Provider Demographics
NPI:1629561436
Name:DILLARD, MARY L (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:DILLARD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 JOHN MADDOX DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1419
Mailing Address - Country:US
Mailing Address - Phone:706-235-0116
Mailing Address - Fax:706-235-5533
Practice Address - Street 1:107 JOHN MADDOX DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1419
Practice Address - Country:US
Practice Address - Phone:706-235-0116
Practice Address - Fax:706-235-5533
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN164344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily