Healthcare Provider Details

I. General information

NPI: 1679335335
Provider Name (Legal Business Name): GABRIELLE WIENCKOSKI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 S BABCOCK ST STE 1
MELBOURNE FL
32901-1459
US

IV. Provider business mailing address

675 S BABCOCK ST
MELBOURNE FL
32901-1459
US

V. Phone/Fax

Practice location:
  • Phone: 321-951-1010
  • Fax: 321-951-1010
Mailing address:
  • Phone: 321-951-1010
  • Fax: 321-952-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberAPRN11030359
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: