Provider Demographics
NPI:1548976061
Name:GOURLEY, VIRGINIA GRACE
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:GRACE
Last Name:GOURLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 W 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-3369
Practice Address - Country:US
Practice Address - Phone:912-537-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program