Provider Demographics
NPI:1003777434
Name:ROBERSON, LILLIAN DECARLA
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:DECARLA
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 DIXON RD
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39082-4400
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:
Practice Address - Street 1:172 DIXON RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39082-4400
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-24
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10037774343747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty