Healthcare Provider Details

I. General information

NPI: 1710255518
Provider Name (Legal Business Name): ANGELA MARIE GILILLAND PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 REVIS ST
BENTON AR
72015-4648
US

IV. Provider business mailing address

519 REVIS ST
BENTON AR
72015-4648
US

V. Phone/Fax

Practice location:
  • Phone: 479-495-0651
  • Fax: 479-495-2622
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2362
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: