Healthcare Provider Details

I. General information

NPI: 1497079834
Provider Name (Legal Business Name): ANGELA LEE GULLEY APRN.CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2010
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 WATERVLIET AVE
DAYTON OH
45420-2705
US

IV. Provider business mailing address

1217 WATERVLIET AVE
DAYTON OH
45420-2705
US

V. Phone/Fax

Practice location:
  • Phone: 937-684-3645
  • Fax:
Mailing address:
  • Phone: 937-684-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0041960
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: