Provider Demographics
NPI:1124540794
Name:FALL-KOFFI, GAELLE ANTA
Entity Type:Individual
Prefix:
First Name:GAELLE
Middle Name:ANTA
Last Name:FALL-KOFFI
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 1:15253 10TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1216
Mailing Address - Country:US
Mailing Address - Phone:646-730-2328
Mailing Address - Fax:
Practice Address - Street 1:152-53, 10TH AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357
Practice Address - Country:US
Practice Address - Phone:646-730-2328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator