Basic Information
Provider Information | |||||||||
NPI: | 1194836627 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILLEN | ||||||||
FirstName: | ERIN | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1351 ROUTE 55 | ||||||||
Address2: | SUITE 101 | ||||||||
City: | LAGRANGEVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 125405108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454759600 | ||||||||
FaxNumber: | 8454759915 | ||||||||
Practice Location | |||||||||
Address1: | 1 COLUMBIA ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | POUGHKEEPSIE | ||||||||
State: | NY | ||||||||
PostalCode: | 126013923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454731188 | ||||||||
FaxNumber: | 8454730896 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 12/29/2016 | ||||||||
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 | 363L00000X | F303896 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LA2200X | F303896 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 02433287 | 05 | NY |   | MEDICAID |