Provider Demographics
NPI:1164844056
Name:GILLISON, NOVERIA
Entity Type:Individual
Prefix:
First Name:NOVERIA
Middle Name:
Last Name:GILLISON
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 1:8618 77TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1033
Mailing Address - Country:US
Mailing Address - Phone:347-886-6626
Mailing Address - Fax:
Practice Address - Street 1:8618 77TH ST
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-1033
Practice Address - Country:US
Practice Address - Phone:347-886-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY495937041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist