Provider Demographics
NPI:1366072266
Name:GILL, MIRISHKA ELIZABETH
Entity type:Individual
Prefix:
First Name:MIRISHKA
Middle Name:ELIZABETH
Last Name:GILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 N 85TH PL
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-8669
Mailing Address - Country:US
Mailing Address - Phone:480-587-0091
Mailing Address - Fax:
Practice Address - Street 1:139 N 85TH PL
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-8669
Practice Address - Country:US
Practice Address - Phone:480-587-0091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-19
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174N00000X, 374J00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty