Provider Demographics
NPI:1720198237
Name:GILLIAM, MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3338 ROSE ARBOR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-4065
Mailing Address - Country:US
Mailing Address - Phone:770-723-0330
Mailing Address - Fax:
Practice Address - Street 1:3338 ROSE ARBOR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-4065
Practice Address - Country:US
Practice Address - Phone:770-723-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN029921367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered