Healthcare Provider Details

I. General information

NPI: 1811535065
Provider Name (Legal Business Name): CHRISTOPHER GRAY GULLEDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 01/05/2020
Certification Date: 01/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 US HIGHWAY 431
BOAZ AL
35957-5908
US

IV. Provider business mailing address

1045 COVE RD
SOUTHSIDE AL
35907-0577
US

V. Phone/Fax

Practice location:
  • Phone: 256-593-8310
  • Fax:
Mailing address:
  • Phone: 256-490-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1-136456
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-136456
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: