Provider Demographics
NPI:1417458498
Name:GORLEY, LARRICE TELA
Entity Type:Individual
Prefix:
First Name:LARRICE
Middle Name:TELA
Last Name:GORLEY
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 1:174 EMERALD POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-9409
Mailing Address - Country:US
Mailing Address - Phone:404-401-7204
Mailing Address - Fax:
Practice Address - Street 1:1401 PEACHTREE ST NE STE 105
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3023
Practice Address - Country:US
Practice Address - Phone:470-749-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222604363LP0808X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA363LP0808XMedicaid