Provider Demographics
NPI:1215778998
Name:CLARK, GABRIELLE M
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:M
Last Name:CLARK
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 1:105 IVY AVE
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1426
Mailing Address - Country:US
Mailing Address - Phone:518-225-0439
Mailing Address - Fax:
Practice Address - Street 1:600 FRANKLIN ST STE 204
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2107
Practice Address - Country:US
Practice Address - Phone:518-372-7031
Practice Address - Fax:518-372-7064
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY569650163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse