Provider Demographics
NPI:1194917112
Name:GILLINGHAM, JOAN M (OTC)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:GILLINGHAM
Suffix:
Gender:F
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S KEENE ST
Mailing Address - Street 2:P.O. BOX O
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7199
Mailing Address - Country:US
Mailing Address - Phone:573-443-2402
Mailing Address - Fax:573-443-0574
Practice Address - Street 1:1 S KEENE ST
Practice Address - Street 2:P.O. BOX O
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7199
Practice Address - Country:US
Practice Address - Phone:573-443-2402
Practice Address - Fax:573-443-0574
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
MO054002163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No163W00000XNursing Service ProvidersRegistered Nurse