Provider Demographics
NPI:1376042028
Name:FATA, GILDA R
Entity Type:Individual
Prefix:
First Name:GILDA
Middle Name:R
Last Name:FATA
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 1:97 BEACON HILL DR
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-2442
Mailing Address - Country:US
Mailing Address - Phone:914-393-8697
Mailing Address - Fax:914-674-6690
Practice Address - Street 1:97 BEACON HILL DR
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-2442
Practice Address - Country:US
Practice Address - Phone:914-393-8697
Practice Address - Fax:914-674-6690
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY589168040174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLDSS-3377Medicaid