Provider Demographics
NPI:1982630117
Name:GILLIAM, PEGGY (CRNA)
Entity Type:Individual
Prefix:
First Name:PEGGY
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 606
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:TN
Mailing Address - Zip Code:38011-0606
Mailing Address - Country:US
Mailing Address - Phone:901-382-1200
Mailing Address - Fax:901-382-8070
Practice Address - Street 1:263 MORRIS RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-7271
Practice Address - Country:US
Practice Address - Phone:901-382-1200
Practice Address - Fax:901-382-8070
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34677367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3604924Medicare ID - Type Unspecified