Provider Demographics
NPI:1831885292
Name:GILLENWATER, TASHANNA (EDD)
Entity type:Individual
Prefix:DR
First Name:TASHANNA
Middle Name:
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3818 216TH PL
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2725
Mailing Address - Country:US
Mailing Address - Phone:773-269-0301
Mailing Address - Fax:708-964-2178
Practice Address - Street 1:3818 216TH PL
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2725
Practice Address - Country:US
Practice Address - Phone:773-269-0301
Practice Address - Fax:708-964-2178
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3020440133N00000X
IL340416171400000X, 174H00000X
IL171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach