Provider Demographics
NPI:1629143490
Name:GILLIAM, PEGGY ANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ANNE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:MARGARET
Other - Middle Name:ANNE
Other - Last Name:GILLAIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:203 BILL NAVE LOOP
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-5575
Mailing Address - Country:US
Mailing Address - Phone:423-844-4104
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000006845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist