Provider Demographics
NPI:1417401605
Name:WILKERSON, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9702 WESTPORT RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2138
Mailing Address - Country:US
Mailing Address - Phone:502-425-1434
Mailing Address - Fax:502-425-7304
Practice Address - Street 1:9702 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2138
Practice Address - Country:US
Practice Address - Phone:502-425-1434
Practice Address - Fax:502-425-7304
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY018781183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist