Provider Demographics
NPI:1316251317
Name:GULLEY, JENIECE N (PA-C)
Entity type:Individual
Prefix:
First Name:JENIECE
Middle Name:N
Last Name:GULLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENIECE
Other - Middle Name:N
Other - Last Name:ALLIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10040 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4396
Practice Address - Country:US
Practice Address - Phone:803-788-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054416363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical