Healthcare Provider Details

I. General information

NPI: 1932703907
Provider Name (Legal Business Name): TERRY LISHONE GILYARD APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 DUNN AVE
DAYTONA BEACH FL
32114-5301
US

IV. Provider business mailing address

1455 DUNN AVE
DAYTONA BEACH FL
32114-0722
US

V. Phone/Fax

Practice location:
  • Phone: 386-559-7498
  • Fax: 386-698-2003
Mailing address:
  • Phone: 386-323-9600
  • Fax: 386-323-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11010324
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: