Provider Demographics
NPI:1720972284
Name:GILLENWATER, MICHEALE
Entity type:Individual
Prefix:
First Name:MICHEALE
Middle Name:
Last Name:GILLENWATER
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GILLENWATER DR
Mailing Address - Street 2:
Mailing Address - City:YAWKEY
Mailing Address - State:WV
Mailing Address - Zip Code:25573-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 GILLENWATER DR
Practice Address - Street 2:
Practice Address - City:YAWKEY
Practice Address - State:WV
Practice Address - Zip Code:25573-2003
Practice Address - Country:US
Practice Address - Phone:304-541-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide