Provider Demographics
NPI:1922729250
Name:GODFREY, GABRIELLA NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:NICOLE
Last Name:GODFREY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 N 124TH ST APT 163
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1035
Mailing Address - Country:US
Mailing Address - Phone:585-456-7741
Mailing Address - Fax:
Practice Address - Street 1:5555 N PORT WASHINGTON RD STE 300
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4928
Practice Address - Country:US
Practice Address - Phone:414-962-6764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program