Provider Demographics
NPI:1104557685
Name:GULLEY, AMBER TAWANNA
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:TAWANNA
Last Name:GULLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 STEELHEAD LN APT 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-0147
Mailing Address - Country:US
Mailing Address - Phone:909-763-6719
Mailing Address - Fax:
Practice Address - Street 1:800 N RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1189
Practice Address - Country:US
Practice Address - Phone:909-763-6719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care