Provider Demographics
NPI:1497336986
Name:GILLIAM, ANGELICA (MS)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 62ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-2853
Mailing Address - Country:US
Mailing Address - Phone:917-687-1342
Mailing Address - Fax:
Practice Address - Street 1:1757 62ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-2853
Practice Address - Country:US
Practice Address - Phone:917-687-1342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY917-687-1342OtherPHONE