Provider Demographics
NPI:1205984010
Name:GILLIAM, DIERDRE A (MSN, RN, PHN)
Entity type:Individual
Prefix:
First Name:DIERDRE
Middle Name:A
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MSN, RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8425 FERNANDO WAY
Mailing Address - Street 2:
Mailing Address - City:ELVERTA
Mailing Address - State:CA
Mailing Address - Zip Code:95626-9542
Mailing Address - Country:US
Mailing Address - Phone:916-991-5875
Mailing Address - Fax:530-666-7447
Practice Address - Street 1:137 N COTTONWOOD ST
Practice Address - Street 2:STE 2400
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-666-8558
Practice Address - Fax:530-666-7447
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA607502163WA2000X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WA2000XNursing Service ProvidersRegistered NurseAdministrator
Not Answered163WC1500XNursing Service ProvidersRegistered NurseCommunity Health