Healthcare Provider Details

I. General information

NPI: 1750873345
Provider Name (Legal Business Name): GAILYA NICOLE GO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N 1200 W
MIDDLEBURY IN
46540-9372
US

IV. Provider business mailing address

1155 N 1200 W
MIDDLEBURY IN
46540-9372
US

V. Phone/Fax

Practice location:
  • Phone: 574-825-3888
  • Fax: 574-825-3999
Mailing address:
  • Phone: 574-825-3888
  • Fax: 574-825-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008002A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: