1619129764 NPI number — DR. MICHELLE MONIQUE GILLILAND DNP

Table of content: DR. MICHELLE MONIQUE GILLILAND DNP (NPI 1619129764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619129764 NPI number — DR. MICHELLE MONIQUE GILLILAND DNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLILAND
Provider First Name:
MICHELLE
Provider Middle Name:
MONIQUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAXON
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619129764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
61 NORWALK AVE APT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14216-2879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-602-0619
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3980 SHERIDAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14226-1727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-250-2000
Provider Business Practice Location Address Fax Number:
716-250-2040
Provider Enumeration Date:
10/21/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  292797-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 309116 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)