Provider Demographics
NPI:1568897767
Name:GULSBY, TARA PHELPS (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:PHELPS
Last Name:GULSBY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SUMMIT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6410
Mailing Address - Country:US
Mailing Address - Phone:770-989-1668
Mailing Address - Fax:678-388-1759
Practice Address - Street 1:3869 HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3918
Practice Address - Country:US
Practice Address - Phone:678-635-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209319363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143806GMedicaid