Provider Demographics
NPI:1942831201
Name:GILLIAM, AUDREY S (MSN, APRN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:S
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MSN, APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 LEESA DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75072-3327
Mailing Address - Country:US
Mailing Address - Phone:817-201-4545
Mailing Address - Fax:
Practice Address - Street 1:3600 SHIRE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2236
Practice Address - Country:US
Practice Address - Phone:469-333-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144036363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics