Provider Demographics
NPI:1851895569
Name:KUDRNKA, GABRIELLE A (CLC)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:A
Last Name:KUDRNKA
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5182 CABANNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-1611
Mailing Address - Country:US
Mailing Address - Phone:314-482-9900
Mailing Address - Fax:
Practice Address - Street 1:5182 CABANNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1611
Practice Address - Country:US
Practice Address - Phone:314-482-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
283302174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula