Healthcare Provider Details

I. General information

NPI: 1508701954
Provider Name (Legal Business Name): MOLLY DALLAS LEMOINE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 MONTGOMERY ST STE D
MADISON MS
39110-1118
US

IV. Provider business mailing address

161 MONTGOMERY ST STE D
MADISON MS
39110-1118
US

V. Phone/Fax

Practice location:
  • Phone: 601-790-7039
  • Fax:
Mailing address:
  • Phone: 601-790-7039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907062
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: