Healthcare Provider Details

I. General information

NPI: 1114144995
Provider Name (Legal Business Name): GAYLE SHUFORD NICULA ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 S WATER ST
STARKE FL
32091-4511
US

IV. Provider business mailing address

1550 S WATER ST
STARKE FL
32091-4511
US

V. Phone/Fax

Practice location:
  • Phone: 904-368-2480
  • Fax: 904-368-2484
Mailing address:
  • Phone: 904-368-2480
  • Fax: 904-368-2484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP1275408
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: