Provider Demographics
NPI:1700883709
Name:SMITH, GABRIELLA ELIZABETH (PA)
Entity Type:Individual
Prefix:MRS
First Name:GABRIELLA
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3060
Mailing Address - Country:US
Mailing Address - Phone:860-242-8756
Mailing Address - Fax:860-242-3052
Practice Address - Street 1:711 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3060
Practice Address - Country:US
Practice Address - Phone:860-242-8756
Practice Address - Fax:860-242-3052
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000729363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400341167OtherMEDICARE
CT008057590Medicaid
CTP01758342OtherRAILROAD MEDICARE