Provider Demographics
NPI:1811030091
Name:DILLON, PAMELA (FNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:DILLON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ENOCHS ST
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2711
Mailing Address - Country:US
Mailing Address - Phone:601-876-3858
Mailing Address - Fax:601-825-8130
Practice Address - Street 1:113 ENOCHS ST
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2711
Practice Address - Country:US
Practice Address - Phone:601-876-3858
Practice Address - Fax:601-825-8130
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR831743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120305Medicaid
MS00120305Medicaid
MS500001411Medicare ID - Type UnspecifiedPAMELA DILLON