Provider Demographics
NPI:1538642053
Name:GULLICK, LAUREN CAMILLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:CAMILLE
Last Name:GULLICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:CAMILLE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:137 PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-2127
Mailing Address - Country:US
Mailing Address - Phone:662-563-4641
Mailing Address - Fax:662-563-4099
Practice Address - Street 1:137 PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-2127
Practice Address - Country:US
Practice Address - Phone:662-563-4641
Practice Address - Fax:662-563-4099
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902904363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03785311Medicaid