Healthcare Provider Details

I. General information

NPI: 1518534072
Provider Name (Legal Business Name): GABRIELLA LORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3607 SW 30TH ST
DES MOINES IA
50321-2047
US

IV. Provider business mailing address

3607 SW 30TH ST
DES MOINES IA
50321-2047
US

V. Phone/Fax

Practice location:
  • Phone: 515-664-6895
  • Fax:
Mailing address:
  • Phone: 515-664-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: