Provider Demographics
NPI:1174293294
Name:GILLAM, CHARLYNN MARIE
Entity Type:Individual
Prefix:MS
First Name:CHARLYNN
Middle Name:MARIE
Last Name:GILLAM
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 1:16940 HIGHWAY 14 STE C-F
Mailing Address - Street 2:
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93501-1238
Mailing Address - Country:US
Mailing Address - Phone:661-824-5020
Mailing Address - Fax:
Practice Address - Street 1:16940 HIGHWAY 14 STE C-F
Practice Address - Street 2:
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1238
Practice Address - Country:US
Practice Address - Phone:661-824-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist