MEDICARE: AUDRIENA NEYSA GILLAM C.N.A., B.S.T.

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1386988145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDRIENA NEYSA GILLAM C.N.A., B.S.T.

Provider Business Mailing Address
First Line	:	2700 S VALLEY VIEW BLVD APT F13
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-0102
Country	:	US
Telephone Number	:	702-719-9980
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 S VALLEY VIEW BLVD APT F13
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-0102
Country	:	US
Telephone Number	:	702-719-9980
Fax Number	:

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

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	02/08/2013

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