MEDICARE: MISS CHARLYNNE ANDRENITA GULLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1760728919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CHARLYNNE ANDRENITA GULLEY

Provider Business Mailing Address
First Line	:	6219 S INDEPENDENCE AVE
Second Line	:	APT. 120
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-1216
Country	:	US
Telephone Number	:	405-410-5801
Fax Number	:

Provider Business Practice Location Address
First Line	:	6219 S INDEPENDENCE AVE
Second Line	:	APT. 120
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-1216
Country	:	US
Telephone Number	:	405-410-5801
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2012
Last Update Date	:	12/17/2012

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