Basic Information
| Provider Information | |||||||||
| NPI: | 1609400183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLEY | ||||||||
| FirstName: | JORDAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1434 BROADRICK DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307203009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062785961 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1434 BROADRICK DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307203009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062785961 | ||||||||
| FaxNumber: | 7062750280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN292981 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.