Healthcare Provider Details

I. General information

NPI: 1508860289
Provider Name (Legal Business Name): SARA N GILLIS CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HIGHLAND AVE SE STE 100
ROANOKE VA
24013-2218
US

IV. Provider business mailing address

21 HIGHLAND AVE SE STE 100
ROANOKE VA
24013-2218
US

V. Phone/Fax

Practice location:
  • Phone: 540-344-9213
  • Fax: 540-345-7559
Mailing address:
  • Phone: 540-344-9213
  • Fax: 540-345-7559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0001137848
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: