Provider Demographics
NPI:1962034884
Name:GULLETT, COURTNEY DANIELLE (MMS, PA-C, RD, CNSC)
Entity type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:DANIELLE
Last Name:GULLETT
Suffix:
Gender:F
Credentials:MMS, PA-C, RD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:248-325-1551
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007950133V00000X
MI5601010680363A00000X
363A00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program