Provider Demographics
NPI:1558617761
Name:GILLY, JENNIFER LANE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LANE
Last Name:GILLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:504-779-5528
Practice Address - Street 1:4429 CLARA STREET
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115
Practice Address - Country:US
Practice Address - Phone:504-842-5300
Practice Address - Fax:504-779-5528
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2323849Medicaid
MS05431857Medicaid
LA276656YH3UMedicare PIN