Provider Demographics
NPI:1053979153
Name:GILLIAM, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9660 SW SADDLE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-6744
Mailing Address - Country:US
Mailing Address - Phone:503-524-2061
Mailing Address - Fax:
Practice Address - Street 1:4400 NE HALSEY ST BLDG 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1545
Practice Address - Country:US
Practice Address - Phone:503-893-6472
Practice Address - Fax:503-215-6240
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker