Provider Demographics
NPI:1245785435
Name:GULLEY, CHARNELL
Entity Type:Individual
Prefix:MS
First Name:CHARNELL
Middle Name:
Last Name:GULLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WALNUT RD
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1021
Mailing Address - Country:US
Mailing Address - Phone:631-624-6539
Mailing Address - Fax:
Practice Address - Street 1:28 WALNUT RD
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1021
Practice Address - Country:US
Practice Address - Phone:631-624-6539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326363164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse