MEDICARE: ALLIE GAMMILL KNICELY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP126297	TX

General Provider Information

NPI Number	:	1003217928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLIE GAMMILL KNICELY FNP

Provider Business Mailing Address
First Line	:	7228 SYRACUSE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-1737
Country	:	US
Telephone Number	:	501-454-7538
Fax Number	:

Provider Business Practice Location Address
First Line	:	4431 TRAVIS ST APT 110
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-4136
Country	:	US
Telephone Number	:	501-454-7538
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2014
Last Update Date	:	11/07/2019

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