1538287958 NPI number — CAROL DIANE GILLETT ANP

Table of content: CAROL DIANE GILLETT ANP (NPI 1538287958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538287958 NPI number — CAROL DIANE GILLETT ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLETT
Provider First Name:
CAROL
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538287958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1355
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANGLETON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-595-2467
Provider Business Mailing Address Fax Number:
281-595-2467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3818 COUNTY ROAD 36
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGLETON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-595-2467
Provider Business Practice Location Address Fax Number:
281-595-2467
Provider Enumeration Date:
03/26/2007

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: 363LF0000X , with the licence number:  507329 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364SP0808X , with the licence number: 507329 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 167608204 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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