Basic Information
| Provider Information | |||||||||
| NPI: | 1659517951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GULLMAN | ||||||||
| FirstName: | STACI | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 NOTTINGHAM DR E | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322597904 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8087 NORMANDY BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322216646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047815666 | ||||||||
| FaxNumber: | 9047818191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2008 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
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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 | 225200000X | PTA21464 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.