Healthcare Provider Details

I. General information

NPI: 1013171404
Provider Name (Legal Business Name): GABRIELLE ROSE THRAILKILL LLM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W DEQUINCY AVE
DE QUEEN AR
71832-2423
US

IV. Provider business mailing address

315 W DEQUINCY AVE
DE QUEEN AR
71832-2423
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-5035
  • Fax:
Mailing address:
  • Phone: 870-642-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberR78711
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: