Healthcare Provider Details

I. General information

NPI: 1619538782
Provider Name (Legal Business Name): GABRIELLE ALYSON KOBACKER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 BISHOP ST
PORTLAND ME
04103-2659
US

IV. Provider business mailing address

5 ELIJAH JAMES DR UNIT 101
SACO ME
04072-1685
US

V. Phone/Fax

Practice location:
  • Phone: 207-618-9611
  • Fax:
Mailing address:
  • Phone: 207-907-9197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberCNP191153
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: