Provider Demographics
NPI:1710393301
Name:GILLIARD, MAMIE LEE
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:LEE
Last Name:GILLIARD
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 1:3503 OSAGE CT
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-4533
Mailing Address - Country:US
Mailing Address - Phone:706-284-2441
Mailing Address - Fax:
Practice Address - Street 1:3503 OSAGE CT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-4533
Practice Address - Country:US
Practice Address - Phone:706-284-2441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALCB20140000963376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide