Provider Demographics
NPI:1295722718
Name:GULLICK, NICOLE M (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:GULLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:ECKERSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6367 E TANQUE VERDE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3832
Mailing Address - Country:US
Mailing Address - Phone:520-290-5888
Mailing Address - Fax:520-290-5551
Practice Address - Street 1:6367 E TANQUE VERDE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3832
Practice Address - Country:US
Practice Address - Phone:520-290-5888
Practice Address - Fax:520-290-5551
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23648207Q00000X
NV16213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ401604-03Medicaid
NV1295722718Medicaid
AZ401604-03Medicaid
AZG49310Medicare UPIN
NV1295722718Medicaid