Provider Demographics
NPI:1710317391
Name:GILLISON, ANGIE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:GILLISON
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 1:633 HIERS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2831
Mailing Address - Country:US
Mailing Address - Phone:843-782-4512
Mailing Address - Fax:843-782-3853
Practice Address - Street 1:633 HIERS CORNER RD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2831
Practice Address - Country:US
Practice Address - Phone:843-782-4512
Practice Address - Fax:843-782-3853
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC71700163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse