Provider Demographics
NPI:1730623018
Name:SMITH, GABRIELLE ELIZABETH
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ELIZABETH
Last Name:SMITH
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 1:7820 HEMINGWAY AVE S APT 3
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4759
Mailing Address - Country:US
Mailing Address - Phone:651-263-2819
Mailing Address - Fax:
Practice Address - Street 1:2795 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1176
Practice Address - Country:US
Practice Address - Phone:651-846-9246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN714834183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician