Provider Demographics
NPI:1932449790
Name:GILLES, PHILLIP (LPN)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:GILLES
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 JACLIF CT
Mailing Address - Street 2:A
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4400
Mailing Address - Country:US
Mailing Address - Phone:786-266-4119
Mailing Address - Fax:
Practice Address - Street 1:2711 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1366
Practice Address - Country:US
Practice Address - Phone:850-769-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5185858164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse