Healthcare Provider Details

I. General information

NPI: 1669780797
Provider Name (Legal Business Name): GINA BETH SCULLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 BOWLING GREEN TRL
RALEIGH NC
27613-6280
US

IV. Provider business mailing address

2000 BOWLING GREEN TRL
RALEIGH NC
27613-6280
US

V. Phone/Fax

Practice location:
  • Phone: 919-500-9982
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number641114
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number242063
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4373
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: