Provider Demographics
NPI:1679538318
Name:GULISH, HEATHER M (MSN, CUNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:GULISH
Suffix:
Gender:F
Credentials:MSN, CUNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3200
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:20952 E 12 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3200
Practice Address - Country:US
Practice Address - Phone:586-771-4820
Practice Address - Fax:586-771-6620
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704180714363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500013142OtherRAILROAD MEDICARE
MI500013142OtherRAILROAD MEDICARE
MIP16868Medicare UPIN
MIP12960001Medicare PIN