Provider Demographics
NPI:1376186809
Name:GULLEY, NICHOLE MARIE (AGCNS)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:GULLEY
Suffix:
Gender:F
Credentials:AGCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4696 WINTER LN
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-2410
Mailing Address - Country:US
Mailing Address - Phone:216-409-1528
Mailing Address - Fax:
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNS.019325364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health