Healthcare Provider Details

I. General information

NPI: 1942886064
Provider Name (Legal Business Name): SHANICE LATOYA GILLIAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 VICTORY RD
SPRINGFIELD OH
45504-3737
US

IV. Provider business mailing address

653 VICTORY RD
SPRINGFIELD OH
45504-3737
US

V. Phone/Fax

Practice location:
  • Phone: 937-215-2107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: