Provider Demographics
NPI:1669024576
Name:GILLIAM, KATINA L
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:L
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 CARNEAL ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-2412
Mailing Address - Country:US
Mailing Address - Phone:804-496-0752
Mailing Address - Fax:
Practice Address - Street 1:1800 CARNEAL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-2412
Practice Address - Country:US
Practice Address - Phone:804-496-0752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker