Provider Demographics
NPI:1568894210
Name:GILLILAN, AMANDA RAE (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:GILLILAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RAE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 EASTWOOD RD
Mailing Address - Street 2:APT 246
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1402 HOSPITAL PLAZA DR APT 419
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6655
Practice Address - Country:US
Practice Address - Phone:910-762-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP14426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist