Healthcare Provider Details

I. General information

NPI: 1184532962
Provider Name (Legal Business Name): GABRIELLE BREANN CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GABRIELLE HAMILTON

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4160
US

IV. Provider business mailing address

9438 W STATE ROAD 28
WEST LEBANON IN
47991-8065
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28274947A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: