1356539456 NPI number — DR. SANDRA LAING GILLAM SANDRA GILLAM

Table of content: DR. SANDRA LAING GILLAM SANDRA GILLAM (NPI 1356539456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356539456 NPI number — DR. SANDRA LAING GILLAM SANDRA GILLAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLAM
Provider First Name:
SANDRA
Provider Middle Name:
LAING
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
SANDRA GILLAM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILLAM
Provider Other First Name:
SANDI
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1356539456
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1028 EASTRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84321-4990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1028 EASTRIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-4990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-9629
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2007

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: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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