Healthcare Provider Details

I. General information

NPI: 1174526883
Provider Name (Legal Business Name): DARIE S. GILLIAM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11990 JACKSON ST
CLINTON LA
70722-3210
US

IV. Provider business mailing address

PO BOX 395
CLINTON LA
70722-0395
US

V. Phone/Fax

Practice location:
  • Phone: 225-683-5292
  • Fax: 225-683-3411
Mailing address:
  • Phone: 225-683-5292
  • Fax: 225-683-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number84714-2755
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: