Provider Demographics
NPI:1700440666
Name:GILLARD, MARQUISA DENISE
Entity Type:Individual
Prefix:
First Name:MARQUISA
Middle Name:DENISE
Last Name:GILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E MIRROR LAKE DR APT A
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-3274
Mailing Address - Country:US
Mailing Address - Phone:352-504-9261
Mailing Address - Fax:
Practice Address - Street 1:217 E MIRROR LAKE DR APT A
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-3274
Practice Address - Country:US
Practice Address - Phone:352-504-9261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities