Healthcare Provider Details

I. General information

NPI: 1932782943
Provider Name (Legal Business Name): TIERRA GILLIAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 DARTMOUTH RD APT B
BALTIMORE MD
21212-3124
US

IV. Provider business mailing address

814 DARTMOUTH RD APT B
BALTIMORE MD
21212-3124
US

V. Phone/Fax

Practice location:
  • Phone: 410-572-7801
  • Fax:
Mailing address:
  • Phone: 410-572-7801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberA00126215
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: