Provider Demographics
NPI:1750589024
Name:GULLEY, VICKY L (DO)
Entity type:Individual
Prefix:MS
First Name:VICKY
Middle Name:L
Last Name:GULLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VICKY
Other - Middle Name:L
Other - Last Name:POUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-0777
Mailing Address - Country:US
Mailing Address - Phone:877-406-2662
Mailing Address - Fax:
Practice Address - Street 1:101 PROGRESS PKWY
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2359
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007013967207P00000X, 207Q00000X
MO2007013987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207308206Medicaid
MO207308206Medicaid