Provider Demographics
NPI:1720318314
Name:GILLILAND, SHAVAUN ERIN (LMT)
Entity Type:Individual
Prefix:MS
First Name:SHAVAUN
Middle Name:ERIN
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 LOMAS BLVD NW
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1962
Mailing Address - Country:US
Mailing Address - Phone:505-967-5358
Mailing Address - Fax:
Practice Address - Street 1:1020 LOMAS BLVD NW
Practice Address - Street 2:SUITE 2A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1962
Practice Address - Country:US
Practice Address - Phone:505-967-5358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6459174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist