Basic Information
| Provider Information | |||||||||
| NPI: | 1952023905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GULLY | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 W 25 S | ||||||||
| Address2: | |||||||||
| City: | JEROME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833385308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085390837 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2550 ADDISON AVE E STE A | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833016748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2022 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 73596 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.