MEDICARE: JERRI ALLEN-GILLIAM RN

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	163W00000X	Registered Nurse	159265	NC

General Provider Information

NPI Number	:	1912659921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRI ALLEN-GILLIAM RN

Provider Business Mailing Address
First Line	:	2520 CHESTNUT HEIGHTS RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27107-6467
Country	:	US
Telephone Number	:	336-624-2011
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 CHESTNUT HEIGHTS RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27107-6467
Country	:	US
Telephone Number	:	336-624-2011
Fax Number	:

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

Provider Enumeration Date	:	01/20/2022
Last Update Date	:	01/20/2022

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