Basic Information
Provider Information | |||||||||
NPI: | 1174526883 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILLIAM | ||||||||
FirstName: | DARIE | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 395 | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | LA | ||||||||
PostalCode: | 707220395 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256835292 | ||||||||
FaxNumber: | 2256833411 | ||||||||
Practice Location | |||||||||
Address1: | 11990 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | LA | ||||||||
PostalCode: | 707223210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256835292 | ||||||||
FaxNumber: | 2256833411 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2005 | ||||||||
LastUpdateDate: | 05/22/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 84714-2755 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1534935 | 05 | LA |   | MEDICAID | MG0827735 | 01 | LA | DEA | OTHER | 1653047 | 05 | LA |   | MEDICAID |