Provider Demographics
NPI:1700456233
Name:GILLIAM, STEPHANIE NICHOLE SMITH (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICHOLE SMITH
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 1:100 MICHAWN CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8660
Mailing Address - Country:US
Mailing Address - Phone:256-612-3655
Mailing Address - Fax:
Practice Address - Street 1:100 MICHAWN CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8660
Practice Address - Country:US
Practice Address - Phone:256-612-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-150842367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered