Healthcare Provider Details

I. General information

NPI: 1871520635
Provider Name (Legal Business Name): JEAN L GULLICKS APRN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 NODAK DR S
FARGO ND
58103-2333
US

IV. Provider business mailing address

1112 NODAK DR S
FARGO ND
58103-2333
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-6224
  • Fax: 701-232-4687
Mailing address:
  • Phone: 701-232-6224
  • Fax: 701-232-4687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR16783
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: