Provider Demographics
NPI:1255174546
Name:NEILL, GABRIELLE N (PAC)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:N
Last Name:NEILL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-404-8200
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:242 BRUNSWICK ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468-1613
Practice Address - Country:US
Practice Address - Phone:207-276-1288
Practice Address - Fax:078-276-6052
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
MEPA2744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program