Provider Demographics
NPI:1104252873
Name:GILL, KAYWANA KHADIJAH (LPN)
Entity type:Individual
Prefix:MRS
First Name:KAYWANA
Middle Name:KHADIJAH
Last Name:GILL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CHURCH STREET APT 8E
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-8551
Mailing Address - Country:US
Mailing Address - Phone:845-629-8818
Mailing Address - Fax:
Practice Address - Street 1:8 CHURCH STREET APT 8E
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-8551
Practice Address - Country:US
Practice Address - Phone:845-629-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302475164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse