Provider Demographics
NPI:1508446063
Name:MEDINA, GABRIELLE MERCEDES
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MERCEDES
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:GABRIELLE
Other - Middle Name:M
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4500 45TH AVE PARSONS BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-670-3146
Mailing Address - Fax:
Practice Address - Street 1:4500 45TH AVE PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-670-3146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator