Provider Demographics
NPI:1639683303
Name:GILLUM, AIREN (STNA)
Entity Type:Individual
Prefix:
First Name:AIREN
Middle Name:
Last Name:GILLUM
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27701 TUNGSTEN RD APT 208
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-6024
Mailing Address - Country:US
Mailing Address - Phone:216-203-9419
Mailing Address - Fax:
Practice Address - Street 1:27701 TUNGSTEN RD APT 208
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-6024
Practice Address - Country:US
Practice Address - Phone:216-438-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400486170505376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide