Provider Demographics
NPI:1295488831
Name:GANNETT, GABRIELLA LATTANZI
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:LATTANZI
Last Name:GANNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BILTMORE EST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2822
Mailing Address - Country:US
Mailing Address - Phone:847-502-3561
Mailing Address - Fax:
Practice Address - Street 1:1848 E THOMAS RD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8103
Practice Address - Country:US
Practice Address - Phone:602-456-2342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8953363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty