Provider Demographics
NPI:1902500531
Name:GILLIS, MARLIE (DC)
Entity type:Individual
Prefix:DR
First Name:MARLIE
Middle Name:
Last Name:GILLIS
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:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:KNOB NOSTER
Mailing Address - State:MO
Mailing Address - Zip Code:65336-0144
Mailing Address - Country:US
Mailing Address - Phone:906-399-1681
Mailing Address - Fax:
Practice Address - Street 1:340 WESTOVER RD
Practice Address - Street 2:
Practice Address - City:WHITEMAN AIR FORCE BASE
Practice Address - State:MO
Practice Address - Zip Code:65305-1222
Practice Address - Country:US
Practice Address - Phone:906-399-1681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022047955111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor