Provider Demographics
NPI:1073818134
Name:GILLUM, MARLA M (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARLA
Middle Name:M
Last Name:GILLUM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 CLAYBERG RD
Mailing Address - Street 2:LOT 55
Mailing Address - City:GREENWICH
Mailing Address - State:OH
Mailing Address - Zip Code:44837-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1121 CLAYBERG RD
Practice Address - Street 2:LOT 55
Practice Address - City:GREENWICH
Practice Address - State:OH
Practice Address - Zip Code:44837-9606
Practice Address - Country:US
Practice Address - Phone:419-895-1146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-099486164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse