Provider Demographics
NPI:1891407185
Name:GILLIS, LATRICE MARIE (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:LATRICE
Middle Name:MARIE
Last Name:GILLIS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-6402
Mailing Address - Country:US
Mailing Address - Phone:716-799-2063
Mailing Address - Fax:
Practice Address - Street 1:72 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-6402
Practice Address - Country:US
Practice Address - Phone:716-799-2063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404533363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health