Provider Demographics
NPI:1992187868
Name:GULLICKSON, TIA MICHELLE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:MICHELLE
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 INTERNATIONAL DR
Mailing Address - Street 2:STE. 126
Mailing Address - City:RED LAKE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56750-4665
Mailing Address - Country:US
Mailing Address - Phone:218-253-4606
Mailing Address - Fax:218-253-4681
Practice Address - Street 1:105 INTERNATIONAL DR
Practice Address - Street 2:STE. 126
Practice Address - City:RED LAKE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56750-4665
Practice Address - Country:US
Practice Address - Phone:218-253-4606
Practice Address - Fax:218-253-4681
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 3937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily