Provider Demographics
NPI:1629769450
Name:PALOMBO, GINA (PHD, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:
Last Name:PALOMBO
Suffix:
Gender:F
Credentials:PHD, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47130 LAND ST
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5142
Mailing Address - Country:US
Mailing Address - Phone:586-854-3426
Mailing Address - Fax:
Practice Address - Street 1:5528 METROPOLITAN PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4105
Practice Address - Country:US
Practice Address - Phone:586-854-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704175936363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health