Provider Demographics
NPI:1669001202
Name:MASCIOLI, GABRIELLA RENEE
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:RENEE
Last Name:MASCIOLI
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 1:1075 CHASE PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2948
Mailing Address - Country:US
Mailing Address - Phone:203-709-6560
Mailing Address - Fax:
Practice Address - Street 1:275 MOUNT CARMEL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-1961
Practice Address - Country:US
Practice Address - Phone:203-885-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5128363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program