Provider Demographics
NPI:1831851278
Name:GUTIERREZ, JILLIAN ILLYSE (NP-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ILLYSE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3697 BALLENTINE PIKE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-8669
Mailing Address - Country:US
Mailing Address - Phone:937-925-5475
Mailing Address - Fax:
Practice Address - Street 1:30 W WARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504
Practice Address - Country:US
Practice Address - Phone:937-328-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0029862363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily