Provider Demographics
NPI:1104633627
Name:CONVERSE, GABRIELLA ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:ELIZABETH
Last Name:CONVERSE
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 JUDITH CT
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1337
Mailing Address - Country:US
Mailing Address - Phone:315-391-7550
Mailing Address - Fax:
Practice Address - Street 1:128 RAYMOND HIRSCH PKWY
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-8193
Practice Address - Country:US
Practice Address - Phone:615-672-3027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN6411363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant