Provider Demographics
NPI:1265911473
Name:BUDOFF, GABRIELL (AGNP-C)
Entity type:Individual
Prefix:
First Name:GABRIELL
Middle Name:
Last Name:BUDOFF
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 COOLIDGE AVE APT 412
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1561
Mailing Address - Country:US
Mailing Address - Phone:914-645-4298
Mailing Address - Fax:
Practice Address - Street 1:55 HATCHETTS HILL RD
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1534
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:877-515-7147
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7860363LG0600X
MARN2318664363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner