Provider Demographics
NPI:1811719560
Name:GULLATT, JEREDA
Entity type:Individual
Prefix:
First Name:JEREDA
Middle Name:
Last Name:GULLATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 W. YORK STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-2146
Mailing Address - Country:US
Mailing Address - Phone:215-989-9595
Mailing Address - Fax:
Practice Address - Street 1:637 W. YORK STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-2146
Practice Address - Country:US
Practice Address - Phone:215-989-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA81273601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide