Provider Demographics
NPI:1093419202
Name:GILLIAM, CORTNEE
Entity Type:Individual
Prefix:MS
First Name:CORTNEE
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 COLEMANS XING
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-7042
Mailing Address - Country:US
Mailing Address - Phone:937-642-9495
Mailing Address - Fax:937-642-4590
Practice Address - Street 1:555 COLEMANS XING
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-7042
Practice Address - Country:US
Practice Address - Phone:937-642-9495
Practice Address - Fax:937-642-4590
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017367-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician