Provider Demographics
NPI:1003217928
Name:KNICELY, ALLIE GAMMILL (FNP)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:GAMMILL
Last Name:KNICELY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7228 SYRACUSE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-1737
Mailing Address - Country:US
Mailing Address - Phone:501-454-7538
Mailing Address - Fax:
Practice Address - Street 1:4431 TRAVIS ST APT 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-4136
Practice Address - Country:US
Practice Address - Phone:501-454-7538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126297363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily