Provider Demographics
NPI:1396511184
Name:SAMPSON, GABRIELLA
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:SAMPSON
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 1:368 WHITE CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-9298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5345 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9421
Practice Address - Country:US
Practice Address - Phone:601-927-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program