Provider Demographics
NPI:1942314299
Name:GILLIAM, PENNY (CRNA)
Entity Type:Individual
Prefix:
First Name:PENNY
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:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX746269367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200877301Medicaid
TX200877303Medicaid
FL301352900Medicaid
TX200877302Medicaid
TXP00786663OtherRAILROAD
TX8008UUOtherBLUE CROSS BLUE SHIELD
FLG1916OtherBLUE CROSS BLUE SHIELD
FLG1916OtherBLUE CROSS BLUE SHIELD
TX200877301Medicaid
FLG1916YMedicare PIN
TX8L10198Medicare PIN