Provider Demographics
NPI:1710736921
Name:GILLIAM, DEVANTE
Entity type:Individual
Prefix:
First Name:DEVANTE
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18540 W ONYX AVE
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-4445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18540 W ONYX AVE
Practice Address - Street 2:
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-4445
Practice Address - Country:US
Practice Address - Phone:602-320-6498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide