Provider Demographics
NPI:1679899702
Name:GILLISPIE, ADRAIN
Entity type:Individual
Prefix:
First Name:ADRAIN
Middle Name:
Last Name:GILLISPIE
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 1:11140 OLD ST. CHARLES ROCK RD.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63074
Mailing Address - Country:US
Mailing Address - Phone:314-429-6949
Mailing Address - Fax:
Practice Address - Street 1:11140 OLD SAINT CHARLES RD
Practice Address - Street 2:
Practice Address - City:SAINT ANN
Practice Address - State:MO
Practice Address - Zip Code:63074-2113
Practice Address - Country:US
Practice Address - Phone:314-429-6949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431811807Medicaid