Healthcare Provider Details

I. General information

NPI: 1053979153
Provider Name (Legal Business Name): HEATHER GILLIAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 NE HALSEY ST BLDG 2
PORTLAND OR
97213-1545
US

IV. Provider business mailing address

9660 SW SADDLE DR
BEAVERTON OR
97008-6744
US

V. Phone/Fax

Practice location:
  • Phone: 503-893-6472
  • Fax: 503-215-6240
Mailing address:
  • Phone: 503-524-2061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: