Basic Information
| Provider Information | |||||||||
| NPI: | 1952597791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUILLAUME | ||||||||
| FirstName: | PAULETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6201 58TH AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERDALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207372873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017795884 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 N RIDGE RD | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210433383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107503474 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 09/14/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LP24038 | MD | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.