Provider Demographics
NPI:1487655791
Name:GREMILLION, GEORGIA A (FNP)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:A
Last Name:GREMILLION
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5725
Mailing Address - Country:US
Mailing Address - Phone:573-332-0808
Mailing Address - Fax:573-339-7945
Practice Address - Street 1:408 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5725
Practice Address - Country:US
Practice Address - Phone:573-332-0808
Practice Address - Fax:573-339-7945
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001028811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00609537OtherRAILROAD MEDICARE
MO429097215Medicaid
MOS53474Medicare UPIN
MOP00609537OtherRAILROAD MEDICARE