Provider Demographics
NPI:1770133712
Name:GILLARD, LUCILLE
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:
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 1:464 WHITE OAK LN
Mailing Address - Street 2:
Mailing Address - City:MIDWAY PARK
Mailing Address - State:NC
Mailing Address - Zip Code:28544
Mailing Address - Country:US
Mailing Address - Phone:910-333-5229
Mailing Address - Fax:
Practice Address - Street 1:464 WHITE OAK LN
Practice Address - Street 2:
Practice Address - City:MIDWAY PARK
Practice Address - State:NC
Practice Address - Zip Code:28544-1239
Practice Address - Country:US
Practice Address - Phone:910-333-5229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8MG3HK1NE87Medicaid