Provider Demographics
NPI:1861883514
Name:NUCKOLS, GABRIELA KIM (CRNA)
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:KIM
Last Name:NUCKOLS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:GABRIELA
Other - Middle Name:KIM
Other - Last Name:MCBRIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4754 EMERALD TRACE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6951
Mailing Address - Country:US
Mailing Address - Phone:682-215-8219
Mailing Address - Fax:
Practice Address - Street 1:609 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3836
Practice Address - Country:US
Practice Address - Phone:770-643-5619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127882367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered