Provider Demographics
NPI:1336988757
Name:AULT, GABRIELLE RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:RENEE
Last Name:AULT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1209 S STATE ROAD 57
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-4367
Mailing Address - Country:US
Mailing Address - Phone:812-254-0990
Mailing Address - Fax:812-254-7730
Practice Address - Street 1:120 MAIN ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1234
Practice Address - Country:US
Practice Address - Phone:812-255-3003
Practice Address - Fax:812-255-5449
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004490B152W00000X
IN18004490A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist