Healthcare Provider Details

I. General information

NPI: 1003777434
Provider Name (Legal Business Name): LILLIAN DECARLA ROBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 DIXON RD
HARRISVILLE MS
39082-4400
US

IV. Provider business mailing address

172 DIXON RD
HARRISVILLE MS
39082-4400
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax:
Mailing address:
  • Phone: 601-362-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number1003777434
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: