Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 1-132253 | AL |
N | 363LA2200X | Nurse Practitioner - Adult Health | 1-132253 | AL |
N | 363LC1500X | Nurse Practitioner - Community Health | 1-132253 | AL |
N | 363LF0000X | Nurse Practitioner - Family Medicine | 1-132253 | AL |
N | 363LP0200X | Nurse Practitioner - Pediatrics | 1-132253 | AL |
N | 363LP2300X | Nurse Practitioner - Primary Care | 1-132253 | AL |
NPI | 1295196251 |
---|---|
Provider Name | Kelli Gillman |
First Address | Mobile, AL 36603-5341 |
Second Address | Loxley, AL 36551-2406 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2016 |
Last Update Date | 17/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1-132253 | STATE LICENSE (01) | AL |