Provider Demographics
NPI:1609227974
Name:RUTHERFORD, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:RUTHERFORD
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-293-7330
Practice Address - Street 1:1333 TAYLOR ST
Practice Address - Street 2:SUITE 6F
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2923
Practice Address - Country:US
Practice Address - Phone:803-296-3273
Practice Address - Fax:803-296-7061
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4535Medicaid