Basic Information
| Provider Information | |||||||||
| NPI: | 1447537105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | LORI | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 2M | ||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064871818 | ||||||||
| FaxNumber: | 6064878448 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 2M | ||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064871818 | ||||||||
| FaxNumber: | 6064878448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2011 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3007224 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.