Provider Demographics
NPI:1518241728
Name:GILLUM, STEPHANIE MARIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:GILLUM
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 1:2 BAILEY ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-9225
Mailing Address - Country:US
Mailing Address - Phone:419-344-0835
Mailing Address - Fax:
Practice Address - Street 1:2 BAILEY ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-9225
Practice Address - Country:US
Practice Address - Phone:419-344-0835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401304601011376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide