Healthcare Provider Details

I. General information

NPI: 1356584288
Provider Name (Legal Business Name): GWENDOLYN GILLIAM RRT, RCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E ARLINGTON BLVD STE M
GREENVILLE NC
27858-5022
US

IV. Provider business mailing address

204 E ARLINGTON BLVD STE M
GREENVILLE NC
27858-5022
US

V. Phone/Fax

Practice location:
  • Phone: 252-321-9300
  • Fax: 252-321-9390
Mailing address:
  • Phone: 252-321-9300
  • Fax: 252-321-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number2199
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: