Provider Demographics
NPI:1588278964
Name:GILLIAM, TONYA
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:GILLIAM
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 1:600 LEGACY DR APT 1326
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-2216
Mailing Address - Country:US
Mailing Address - Phone:972-632-6877
Mailing Address - Fax:888-206-1272
Practice Address - Street 1:4099 MCEWEN RD STE 550
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75244-5353
Practice Address - Country:US
Practice Address - Phone:972-632-6877
Practice Address - Fax:888-206-1272
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty