Provider Demographics
NPI:1104298116
Name:GILLIAM, MELODY (RN)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:ANN
Other - Last Name:LAWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:1596 HIGHWAY 33 S
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-7104
Practice Address - Country:US
Practice Address - Phone:423-626-8271
Practice Address - Fax:865-342-0106
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN200435163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health