Provider Demographics
NPI:1457082034
Name:GILLER, AYVERIE LUCILLE
Entity Type:Individual
Prefix:
First Name:AYVERIE
Middle Name:LUCILLE
Last Name:GILLER
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 1:977 BOLTON FARMS LN
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-9796
Mailing Address - Country:US
Mailing Address - Phone:517-242-5406
Mailing Address - Fax:
Practice Address - Street 1:977 BOLTON FARMS LN
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-9796
Practice Address - Country:US
Practice Address - Phone:517-242-5406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty