Healthcare Provider Details

I. General information

NPI: 1356547251
Provider Name (Legal Business Name): PRISCILLA LEE GULLIVER M.S.,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 A1A S SUITE 104
ST AUGUSTINE FL
32080-6591
US

IV. Provider business mailing address

2180 A1A S SUITE 104
ST AUGUSTINE FL
32080-6591
US

V. Phone/Fax

Practice location:
  • Phone: 904-347-7497
  • Fax: 904-797-7812
Mailing address:
  • Phone: 904-347-7497
  • Fax: 904-797-7812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA18779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: