Provider Demographics
NPI:1689438293
Name:GABOURY, KAELYNN RENEE
Entity Type:Individual
Prefix:
First Name:KAELYNN
Middle Name:RENEE
Last Name:GABOURY
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 1:250 RUTLEDGE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5691
Mailing Address - Country:US
Mailing Address - Phone:413-544-8560
Mailing Address - Fax:
Practice Address - Street 1:250 RUTLEDGE AVE APT B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5691
Practice Address - Country:US
Practice Address - Phone:413-544-8560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant