Provider Demographics
NPI:1821297698
Name:GILLIAM, GRETTA LYNN (DNP, ARNP, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:GRETTA
Middle Name:LYNN
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:DNP, ARNP, FNP-C
Other - Prefix:MS
Other - First Name:GRETTA
Other - Middle Name:LYNN
Other - Last Name:NATION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN,,MSN, ARNP-C
Mailing Address - Street 1:1850 W REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5730
Mailing Address - Country:US
Mailing Address - Phone:417-891-4800
Mailing Address - Fax:417-891-4913
Practice Address - Street 1:1850 W REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5730
Practice Address - Country:US
Practice Address - Phone:417-891-4800
Practice Address - Fax:417-891-4913
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138082363LA2200X, 363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health