Provider Demographics
NPI:1861895336
Name:TASSELL, GAYLEN Q (NP)
Entity type:Individual
Prefix:
First Name:GAYLEN
Middle Name:Q
Last Name:TASSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12340 BERMUDA CROSSROAD LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-2352
Mailing Address - Country:US
Mailing Address - Phone:804-287-4550
Mailing Address - Fax:804-717-8292
Practice Address - Street 1:12340 BERMUDA CROSSROAD LN
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-2352
Practice Address - Country:US
Practice Address - Phone:804-287-4550
Practice Address - Fax:804-717-8292
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164429363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN