Provider Demographics
NPI:1306927306
Name:GILLOW, BRYN ALEXA (DC)
Entity type:Individual
Prefix:
First Name:BRYN
Middle Name:ALEXA
Last Name:GILLOW
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC1 BOX 10
Mailing Address - Street 2:
Mailing Address - City:BRODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322-9660
Mailing Address - Country:US
Mailing Address - Phone:570-992-2929
Mailing Address - Fax:570-992-3221
Practice Address - Street 1:HC 1 BOX 10
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-9660
Practice Address - Country:US
Practice Address - Phone:570-992-2929
Practice Address - Fax:570-992-3221
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007914L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1783617OtherAMERIHEALTH
PA2622014000OtherINDEP PERSONAL CHOICE
PA819689OtherFIRST PRIORITY
PA9701133OtherGHI
PA2622014000OtherINDEP PERSONAL CHOICE