Provider Demographics
NPI:1851800601
Name:WALTON, GABRIELLA ROSE
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:ROSE
Last Name:WALTON
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 1:124 KILLDEER CT
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1333
Mailing Address - Country:US
Mailing Address - Phone:1407-883-9282
Mailing Address - Fax:
Practice Address - Street 1:1219 DUNN AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2405
Practice Address - Country:US
Practice Address - Phone:386-255-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8321235Z00000X
FLSA16645235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist