Healthcare Provider Details

I. General information

NPI: 1487487302
Provider Name (Legal Business Name): TARA CHERRELLE GILLIAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL RD
PATCHOGUE NY
11772-4870
US

IV. Provider business mailing address

158 MARK TREE RD
CENTEREACH NY
11720-2238
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-7100
  • Fax:
Mailing address:
  • Phone: 631-740-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311842
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: