Provider Demographics
NPI:1255487724
Name:MATHIESON-DEVEREAUX, GAIL ANN (FNP)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:ANN
Last Name:MATHIESON-DEVEREAUX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 GILLEN DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-5942
Mailing Address - Country:US
Mailing Address - Phone:607-722-7659
Mailing Address - Fax:
Practice Address - Street 1:4211 STATE HIGHWAY 220
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NY
Practice Address - Zip Code:13830-4305
Practice Address - Country:US
Practice Address - Phone:607-843-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330362363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily