Provider Demographics
NPI:1063465771
Name:GABRIEL, LYNNELLE RENEE (DPM)
Entity Type:Individual
Prefix:
First Name:LYNNELLE
Middle Name:RENEE
Last Name:GABRIEL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 GRIFFIN ST E
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1439
Mailing Address - Country:US
Mailing Address - Phone:715-268-8000
Mailing Address - Fax:715-268-0311
Practice Address - Street 1:265 GRIFFIN ST E
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1439
Practice Address - Country:US
Practice Address - Phone:715-268-0308
Practice Address - Fax:715-268-0311
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI763-025213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43240800Medicaid
WI000056016Medicare PIN
WI43240800Medicaid
WI000049011Medicare PIN