Provider Demographics
NPI:1225050198
Name:GILLIAM, ELAINE (MNT)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 664056
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46266-4056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5230 E STOP 11 RD
Practice Address - Street 2:SUITE 150
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6339
Practice Address - Country:US
Practice Address - Phone:317-865-5904
Practice Address - Fax:317-865-5321
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered