Provider Demographics
NPI:1356523161
Name:GULLICKSEN, LAURA A (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:A
Last Name:GULLICKSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:SLAUGHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4935 SAVANNAH RUN
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0280
Mailing Address - Country:US
Mailing Address - Phone:678-549-1681
Mailing Address - Fax:
Practice Address - Street 1:6325 W JOHNS XING
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-5746
Practice Address - Country:US
Practice Address - Phone:404-778-8311
Practice Address - Fax:770-495-1585
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2010-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN144532367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00834094AMedicaid
586565Medicare UPIN
GA00834094AMedicaid