Provider Demographics
NPI:1548016793
Name:GILLIES, MANYA GORDON (NP)
Entity type:Individual
Prefix:
First Name:MANYA
Middle Name:GORDON
Last Name:GILLIES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MANYA
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-9516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT101.0137162363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program