Provider Demographics
NPI:1417935586
Name:GULLICKSON, KIMBERLY KAY (AUD CCC-A)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:KAY
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 TURNER STREET
Mailing Address - Street 2:BRANCH HEALTH CLINIC NAVAL AIR STATION
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32508
Mailing Address - Country:US
Mailing Address - Phone:850-452-5242
Mailing Address - Fax:
Practice Address - Street 1:450 TURNER STREET
Practice Address - Street 2:BRANCH HEALTH CLINIC NAVAL AIR STATION
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508
Practice Address - Country:US
Practice Address - Phone:850-452-5242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT005774231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist