Provider Demographics
NPI:1124302468
Name:GILLAM, SHERRI L (CNP)
Entity type:Individual
Prefix:
First Name:SHERRI
Middle Name:L
Last Name:GILLAM
Suffix:
Gender:
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CENTRE ST PH 120
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4559
Mailing Address - Country:US
Mailing Address - Phone:888-731-8994
Mailing Address - Fax:833-775-1861
Practice Address - Street 1:139 CENTRE ST PH 120
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4559
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:833-775-1861
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019684363LW0102X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109815Medicaid