Healthcare Provider Details

I. General information

NPI: 1750589024
Provider Name (Legal Business Name): VICKY L GULLEY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKY L POUCHER DO

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PROGRESS PKWY
SULLIVAN MO
63080-2359
US

IV. Provider business mailing address

PO BOX 777
RICHLAND MO
65556-0777
US

V. Phone/Fax

Practice location:
  • Phone: 844-853-8937
  • Fax:
Mailing address:
  • Phone: 877-406-2662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2007013967
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007013987
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007013967
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier207308206
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: