Provider Demographics
NPI:1790055218
Name:TULLIS, GWEN HIRSH (LMBT)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:HIRSH
Last Name:TULLIS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 LAKE ROYALE
Mailing Address - Street 2:107 SHOSHONE DRIVE
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-9517
Mailing Address - Country:US
Mailing Address - Phone:919-616-5839
Mailing Address - Fax:
Practice Address - Street 1:282 LAKE ROYALE
Practice Address - Street 2:107 SHOSHONE DRIVE
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-9517
Practice Address - Country:US
Practice Address - Phone:919-616-5839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-02
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker