Provider Demographics
NPI:1710606694
Name:GILLIAM, JALA NICOLE (DPT, PT)
Entity Type:Individual
Prefix:
First Name:JALA
Middle Name:NICOLE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2096
Mailing Address - Country:US
Mailing Address - Phone:716-342-1100
Mailing Address - Fax:
Practice Address - Street 1:2633 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2096
Practice Address - Country:US
Practice Address - Phone:716-342-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY049102OtherNYS LICENSE