Provider Demographics
NPI:1346083649
Name:SMITH, GABRIELLE DIANE
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:DIANE
Last Name:SMITH
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 1:12143 FAHRPARK LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4763
Mailing Address - Country:US
Mailing Address - Phone:314-249-1844
Mailing Address - Fax:
Practice Address - Street 1:1111 W 17TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-1886
Practice Address - Country:US
Practice Address - Phone:314-249-1844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program