Provider Demographics
NPI:1528743887
Name:GULLEY, KRISTOPHER LAMAR SR
Entity type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:LAMAR
Last Name:GULLEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4677 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-9329
Mailing Address - Country:US
Mailing Address - Phone:330-388-9952
Mailing Address - Fax:
Practice Address - Street 1:4677 SCENIC DR
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9329
Practice Address - Country:US
Practice Address - Phone:330-388-9952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver