Provider Demographics
NPI:1184082661
Name:GILLIS, TARYN BENSON (NP-C)
Entity type:Individual
Prefix:MRS
First Name:TARYN
Middle Name:BENSON
Last Name:GILLIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:TARYN
Other - Middle Name:LEIGH
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7130
Mailing Address - Fax:239-343-7185
Practice Address - Street 1:9800 S HEALTHPARK DR STE 205
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-7130
Practice Address - Fax:239-343-7185
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9307733367A00000X
FLARNP9307733363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115776000Medicaid