Provider Demographics
NPI:1932574670
Name:MILLIS, GAYLE (LPN)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:MILLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 E CAROLLTON DR
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4165
Mailing Address - Country:US
Mailing Address - Phone:262-989-2366
Mailing Address - Fax:414-304-5866
Practice Address - Street 1:3260 E CAROLLTON DR
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-4165
Practice Address - Country:US
Practice Address - Phone:262-989-2366
Practice Address - Fax:414-304-5866
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0013030320600000X
WI0015707320600000X
WI0014938320600000X
WI0013357320700000X
WI0015444320700000X
WI0014242320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities