Basic Information
| Provider Information | |||||||||
| NPI: | 1548365133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLEY | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 MEDICAL CIR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 FLEMINGSBURG RD | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3004656 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3004656 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0213365 | 01 | KY | MEDICARE ID - 2133 | OTHER | 0216377 | 01 | KY | MEDICARE ID - 2163 | OTHER | 0247263 | 01 | KY | MEDICARE ID - 8158 | OTHER | 1063391 | 01 | KY | MEDICARE ID - 0633 | OTHER | 0074290 | 01 | KY | MEDICARE ID - 8002 | OTHER | 78015815 | 05 | KY | MEDICAID |