Provider Demographics
NPI:1952408130
Name:GILLIS, HOLLIE THACKER (CPNP)
Entity type:Individual
Prefix:
First Name:HOLLIE
Middle Name:THACKER
Last Name:GILLIS
Suffix:
Gender:
Credentials:CPNP
Other - Prefix:
Other - First Name:HOLLIE
Other - Middle Name:EUGENIA
Other - Last Name:THACKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:85 JOHN MADDOX DRIVE CONNECTOR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1233
Practice Address - Country:US
Practice Address - Phone:762-235-2990
Practice Address - Fax:706-238-8031
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN089950363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000776344CMedicaid
GA000776344CMedicaid