Provider Demographics
NPI:1780046854
Name:GILLIAM, RUBY VANESSA LEE (RN)
Entity Type:Individual
Prefix:MRS
First Name:RUBY VANESSA
Middle Name:LEE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:LEE
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:130 WAYNE FRYE DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45144-9314
Mailing Address - Country:US
Mailing Address - Phone:937-549-4777
Mailing Address - Fax:937-549-1286
Practice Address - Street 1:130 WAYNE FRYE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45144-9314
Practice Address - Country:US
Practice Address - Phone:937-549-4777
Practice Address - Fax:937-549-1286
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH280645163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool