Provider Demographics
NPI:1134638489
Name:GILLAM, ELIZABETH BOYLE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BOYLE
Last Name:GILLAM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARGUERITE
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:5522 DELOR ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2803
Mailing Address - Country:US
Mailing Address - Phone:636-399-5338
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017029167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily