Provider Demographics
NPI:1457114720
Name:COOMER, GABRIELLE ANTOINETTE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ANTOINETTE
Last Name:COOMER
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 1:5382 E KINDERHOOK RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-6120
Mailing Address - Country:US
Mailing Address - Phone:270-537-3715
Mailing Address - Fax:
Practice Address - Street 1:555 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3822
Practice Address - Country:US
Practice Address - Phone:270-537-3715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN28263728A163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program