Provider Demographics
NPI:1396834438
Name:GABBART, PHYLLIS (APRN)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:GABBART
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2133
Mailing Address - Country:US
Mailing Address - Phone:618-235-1703
Mailing Address - Fax:618-222-5969
Practice Address - Street 1:305 S ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2133
Practice Address - Country:US
Practice Address - Phone:618-235-1703
Practice Address - Fax:618-222-5969
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04112574363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK37461OtherIL MEDICARE
IL0000304010OtherGROUP IL MEDICARE
IL0000304010OtherGROUP IL MEDICARE