MEDICARE: MS. NIYA JEANETTE GILLUM DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1376001404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NIYA JEANETTE GILLUM DC

Provider Business Mailing Address
First Line	:	2059 38TH ST SE APT 301
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-2440
Country	:	US
Telephone Number	:	202-390-7021
Fax Number	:

Provider Business Practice Location Address
First Line	:	2059 38TH ST SE APT 301
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-2440
Country	:	US
Telephone Number	:	202-390-7021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2019
Last Update Date	:	03/07/2019

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