1063649861 NPI number — CRISTIN AUTREY GILLEY CNM

Table of content: CRISTIN AUTREY GILLEY CNM (NPI 1063649861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063649861 NPI number — CRISTIN AUTREY GILLEY CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLEY
Provider First Name:
CRISTIN
Provider Middle Name:
AUTREY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AUTREY
Provider Other First Name:
CRISTIN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063649861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2003 MEDICAL PKWY
Provider Second Line Business Mailing Address:
SUITE G50
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401-7992
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-573-1094
Provider Business Mailing Address Fax Number:
410-573-1097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2003 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE G50
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-7992
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-573-1094
Provider Business Practice Location Address Fax Number:
410-573-1097
Provider Enumeration Date:
06/18/2009

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: 367A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 417732100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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