Provider Demographics
NPI:1104267392
Name:WOOD, GILLIANNE ALISON (RN)
Entity type:Individual
Prefix:
First Name:GILLIANNE
Middle Name:ALISON
Last Name:WOOD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7901
Mailing Address - Country:US
Mailing Address - Phone:718-506-4107
Mailing Address - Fax:
Practice Address - Street 1:94 4TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7901
Practice Address - Country:US
Practice Address - Phone:718-506-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY649330-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY649330-1Medicaid