Provider Demographics
NPI:1639699853
Name:POWELL, GABRIELLE MELISSA (PA)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MELISSA
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5256
Mailing Address - Country:US
Mailing Address - Phone:770-720-7733
Mailing Address - Fax:
Practice Address - Street 1:227 RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5256
Practice Address - Country:US
Practice Address - Phone:770-720-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005800363AM0700X
GA10986363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical