Provider Demographics
NPI:1609387174
Name:GULLEDGE, LACY DANIELLE (ARNP)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:DANIELLE
Last Name:GULLEDGE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:75338 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-1609
Mailing Address - Country:US
Mailing Address - Phone:334-208-6190
Mailing Address - Fax:
Practice Address - Street 1:15255 MAX LEGGETT PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7273
Practice Address - Country:US
Practice Address - Phone:904-244-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9429348363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care