Provider Demographics
NPI:1447420062
Name:GILL, ANGIE J (PTA)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:J
Last Name:GILL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 S 22ND ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68147-2101
Mailing Address - Country:US
Mailing Address - Phone:402-238-8917
Mailing Address - Fax:
Practice Address - Street 1:2305 S 10TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68108-1108
Practice Address - Country:US
Practice Address - Phone:402-238-8917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001209225200000X
NE839225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant