Provider Demographics
NPI:1447406236
Name:GULLEY, SHANNON RANAE (BSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RANAE
Last Name:GULLEY
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 U.S. 60 BOX 11
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102
Mailing Address - Country:US
Mailing Address - Phone:606-929-9155
Mailing Address - Fax:606-929-9155
Practice Address - Street 1:5850 U.S. 60 BOX 11
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102
Practice Address - Country:US
Practice Address - Phone:606-929-9155
Practice Address - Fax:606-929-9155
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid