Healthcare Provider Details

I. General information

NPI: 1912388752
Provider Name (Legal Business Name): CAROLYN GAULKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 302
BEND OR
97701-4279
US

IV. Provider business mailing address

5112 W TAFT RD SUITE H
LIVERPOOL NY
13088
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-4220
  • Fax:
Mailing address:
  • Phone: 315-452-3235
  • Fax: 315-410-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number339715
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: