Provider Demographics
NPI:1780348284
Name:GILLILAND, MICHELLE LEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:GILLILAND
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 1:644 LIONS CLUB RD
Mailing Address - Street 2:
Mailing Address - City:TOLLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:41189-8704
Mailing Address - Country:US
Mailing Address - Phone:606-202-1714
Mailing Address - Fax:
Practice Address - Street 1:644 LIONS CLUB RD
Practice Address - Street 2:
Practice Address - City:TOLLESBORO
Practice Address - State:KY
Practice Address - Zip Code:41189-8704
Practice Address - Country:US
Practice Address - Phone:606-202-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018334363LF0000X
KY1124221163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse