Provider Demographics
NPI:1407247752
Name:BERTA, GABRIELLA
Entity Type:Individual
Prefix:MRS
First Name:GABRIELLA
Middle Name:
Last Name:BERTA
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 1:15 FULTON AVE
Mailing Address - Street 2:# LL
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-2315
Mailing Address - Country:US
Mailing Address - Phone:845-562-2191
Mailing Address - Fax:
Practice Address - Street 1:15 FULTON AVE
Practice Address - Street 2:# LL
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603
Practice Address - Country:US
Practice Address - Phone:845-473-8996
Practice Address - Fax:845-473-8997
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33 339390363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY041845439Medicaid