Provider Demographics
NPI:1639652829
Name:GILLIAM, CASSANDRA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2052 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3625
Mailing Address - Country:US
Mailing Address - Phone:478-207-7773
Mailing Address - Fax:877-299-6815
Practice Address - Street 1:2052 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3625
Practice Address - Country:US
Practice Address - Phone:478-207-7773
Practice Address - Fax:877-299-6815
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171251363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health