Provider Demographics
NPI:1134925936
Name:GILLINGHAM, NOREEN MARY (RSA-O)
Entity type:Individual
Prefix:
First Name:NOREEN
Middle Name:MARY
Last Name:GILLINGHAM
Suffix:
Gender:
Credentials:RSA-O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PRUYN PAVILION 102 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-793-5601
Mailing Address - Fax:
Practice Address - Street 1:PRUYN PAVILION 102 PARK STREET
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-1280
Practice Address - Country:US
Practice Address - Phone:518-793-5601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYO000138-01246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant