MEDICARE: STACI GULLMAN PTA

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	225200000X	Physical Therapy Assistant	PTA21464	FL

General Provider Information

NPI Number	:	1659517951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACI GULLMAN PTA

Provider Business Mailing Address
First Line	:	144 NOTTINGHAM DR E
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-7904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8087 NORMANDY BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-6646
Country	:	US
Telephone Number	:	904-781-5666
Fax Number	:	904-781-8191

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

Provider Enumeration Date	:	12/17/2008
Last Update Date	:	12/17/2008

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