Provider Demographics
NPI:1710582812
Name:ATALLA, GISELLE
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:ATALLA
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 1:47 PALOMINO DR
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-3622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 PALOMINO DR
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3622
Practice Address - Country:US
Practice Address - Phone:562-237-4797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03984000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI03984000Medicaid