Provider Demographics
NPI:1376582023
Name:GILLIAM, PATRICIA P (PHD, ARNP)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:P
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PHD, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 LAHARA WAY
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4650
Mailing Address - Country:US
Mailing Address - Phone:727-452-8510
Mailing Address - Fax:
Practice Address - Street 1:1343 LAHARA WAY
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4650
Practice Address - Country:US
Practice Address - Phone:727-452-8510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3095392363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303394500Medicaid
FLE4985XMedicare ID - Type UnspecifiedMEDICARE
FL303394500Medicaid