Provider Demographics
NPI:1003308776
Name:GILLHAM, VICKI JANELLE (RN)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:JANELLE
Last Name:GILLHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1481
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-1481
Mailing Address - Country:US
Mailing Address - Phone:512-620-2799
Mailing Address - Fax:
Practice Address - Street 1:502 OLD BROCK ROAD #134
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76088
Practice Address - Country:US
Practice Address - Phone:512-620-2799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX695658163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse