Provider Demographics
NPI:1568739522
Name:GILLEN, TIMOTHY (RN)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:GILLEN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 ELKHART ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1710
Mailing Address - Country:US
Mailing Address - Phone:718-608-5894
Mailing Address - Fax:
Practice Address - Street 1:77 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3757
Practice Address - Country:US
Practice Address - Phone:718-442-7828
Practice Address - Fax:718-556-2516
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY514154163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse