Provider Demographics
NPI:1922660174
Name:GULLEY, LTRICE TRINETTE (APN)
Entity Type:Individual
Prefix:
First Name:LTRICE
Middle Name:TRINETTE
Last Name:GULLEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MCCLINTOCK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:630-655-6748
Mailing Address - Fax:
Practice Address - Street 1:1300 FRANKLIN AVE STE 230C
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3709
Practice Address - Country:US
Practice Address - Phone:309-585-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018718363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily