Healthcare Provider Details

I. General information

NPI: 1124089735
Provider Name (Legal Business Name): JULIE ILUMIN GOTICO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

4908 BURNLEY DR
WILLIAMSBURG VA
23188-8802
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone: 757-229-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024053889
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: