Provider Demographics
NPI:1639936016
Name:GULLEY, CHIVON MONIQUE
Entity Type:Individual
Prefix:
First Name:CHIVON
Middle Name:MONIQUE
Last Name:GULLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 SE 87TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-6080
Mailing Address - Country:US
Mailing Address - Phone:405-474-0598
Mailing Address - Fax:
Practice Address - Street 1:2629 W I 44 SERVICE RD STE 202
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3762
Practice Address - Country:US
Practice Address - Phone:405-919-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty