Provider Demographics
NPI:1093078602
Name:GILL, SANDRA DEANN (PTA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DEANN
Last Name:GILL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15891 OAKDALE BLACKTOP RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-6213
Mailing Address - Country:US
Mailing Address - Phone:618-336-5433
Mailing Address - Fax:
Practice Address - Street 1:15891 OAKDALE BLACKTOP RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-6213
Practice Address - Country:US
Practice Address - Phone:618-336-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant