Provider Demographics
NPI:1801333885
Name:GILLILAND, IRENE LYDIA (APRN)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:LYDIA
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:LYDIA
Other - Last Name:CHODAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 54136
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79453-4136
Mailing Address - Country:US
Mailing Address - Phone:806-771-1386
Mailing Address - Fax:806-771-1388
Practice Address - Street 1:5224 75TH ST
Practice Address - Street 2:STE D
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2523
Practice Address - Country:US
Practice Address - Phone:806-771-0995
Practice Address - Fax:806-771-3813
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP105151364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical