Provider Demographics
NPI:1043749617
Name:GILLEY, CAROLYN ANN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:GILLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-1795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 CARROLL ST
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1795
Practice Address - Country:US
Practice Address - Phone:800-490-3146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care