Provider Demographics
NPI:1154005825
Name:HEINIKE, GABRIELLA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:HEINIKE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MACCOLLUM RD
Mailing Address - Street 2:
Mailing Address - City:ELBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13060-9709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:329 N SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1755
Practice Address - Country:US
Practice Address - Phone:315-471-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF404993-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health