Healthcare Provider Details

I. General information

NPI: 1417142787
Provider Name (Legal Business Name): MELISSA ANN GILLIAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9981 S HEALTHPARK DR
FORT MYERS FL
33908
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-6860
  • Fax: 239-985-3528
Mailing address:
  • Phone: 239-343-0284
  • Fax: 239-343-0973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103363
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: