Provider Demographics
NPI:1245754563
Name:GILLARD, TANIKA ANNETTE (LMT)
Entity Type:Individual
Prefix:
First Name:TANIKA
Middle Name:ANNETTE
Last Name:GILLARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TANIKA
Other - Middle Name:ANNETTE
Other - Last Name:GILLARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:4 N HAMPTON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3924
Mailing Address - Country:US
Mailing Address - Phone:731-616-7601
Mailing Address - Fax:
Practice Address - Street 1:4 HAMPTON LN
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-616-7601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6375225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty