Healthcare Provider Details

I. General information

NPI: 1962016162
Provider Name (Legal Business Name): PAUL GILLEY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

IV. Provider business mailing address

1185 W MOUNTAIN VIEW RD APT 1107
JOHNSON CITY TN
37604-2527
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-7111
  • Fax:
Mailing address:
  • Phone: 615-957-1275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number00000027539
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: