Healthcare Provider Details

I. General information

NPI: 1477023596
Provider Name (Legal Business Name): LAVECHELLE PILLERS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2018
Last Update Date: 12/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 GALAXIE DR STE 105
JACKSON MS
39206-4354
US

IV. Provider business mailing address

15 JENNIFER CT
MADISON MS
39110-8898
US

V. Phone/Fax

Practice location:
  • Phone: 601-300-3935
  • Fax:
Mailing address:
  • Phone: 769-798-0729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901938
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: