Provider Demographics
NPI:1003300807
Name:GABRIEL, ANGEL
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:GABRIEL
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 1:199 TIM BOLAND RD
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-8629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3387 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3351
Practice Address - Country:US
Practice Address - Phone:850-932-9257
Practice Address - Fax:850-932-5989
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10025OTA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant