Healthcare Provider Details

I. General information

NPI: 1508787128
Provider Name (Legal Business Name): ALLIE GILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 NW BROAD ST
LYONS GA
30436-5648
US

IV. Provider business mailing address

714 NW BROAD ST
LYONS GA
30436-5648
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-8109
  • Fax:
Mailing address:
  • Phone: 912-526-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN299497
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: