Healthcare Provider Details

I. General information

NPI: 1295196251
Provider Name (Legal Business Name): KELLI GILLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1083 E RELHAM DR
LOXLEY AL
36551-2406
US

IV. Provider business mailing address

1303 DR MARTIN L KING JR AVE
MOBILE AL
36603-5341
US

V. Phone/Fax

Practice location:
  • Phone: 251-964-4011
  • Fax: 251-964-4012
Mailing address:
  • Phone: 251-432-4117
  • Fax: 251-436-7765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-132253
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-132253
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number1-132253
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-132253
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-132253
License Number StateAL
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1-132253
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: