Provider Demographics
NPI:1013653286
Name:GULLES, STP JOURNEY (NP)
Entity Type:Individual
Prefix:
First Name:STP JOURNEY
Middle Name:
Last Name:GULLES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 SHAFER CT STE 700
Mailing Address - Street 2:
Mailing Address - City:ROSEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4989
Mailing Address - Country:US
Mailing Address - Phone:346-376-1702
Mailing Address - Fax:224-532-2780
Practice Address - Street 1:4100 LATHAM ST STE E
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1733
Practice Address - Country:US
Practice Address - Phone:951-393-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020502363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology