Provider Demographics
NPI:1164926267
Name:DE ALLIE, GABRIELLE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:MARIE
Last Name:DE ALLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 FARMSTEAD CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1511
Mailing Address - Country:US
Mailing Address - Phone:347-295-8770
Mailing Address - Fax:
Practice Address - Street 1:5000 KY ROUTE 321 STE 3141
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-886-8511
Practice Address - Fax:606-886-1316
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA88990207R00000X
GA390200000X
KYTP707207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100816250Medicaid