Provider Demographics
NPI:1134337017
Name:GABBERT, ELLENDALE WITHERS (C-FNP)
Entity type:Individual
Prefix:MRS
First Name:ELLENDALE
Middle Name:WITHERS
Last Name:GABBERT
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8258
Mailing Address - Fax:337-312-6711
Practice Address - Street 1:501 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5724
Practice Address - Country:US
Practice Address - Phone:337-433-8400
Practice Address - Fax:337-312-6711
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA63422-3267363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1557773Medicaid
LA4C7027460Medicare PIN
LAP00981886Medicare PIN