Provider Demographics
NPI:1871139295
Name:GILLIAM, PATRICIA MOYER (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MOYER
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 SKYVIEW LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3101
Mailing Address - Country:US
Mailing Address - Phone:703-909-9138
Mailing Address - Fax:
Practice Address - Street 1:3805 SKYVIEW LN
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3101
Practice Address - Country:US
Practice Address - Phone:703-909-9138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178407363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health