Provider Demographics
NPI:1699075044
Name:GYOMORY, JACKIE R (ACNP-BC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:R
Last Name:GYOMORY
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN586505363L00000X
IL209.010429363LA2100X
MI4704259474363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner