Healthcare Provider Details

I. General information

NPI: 1366853301
Provider Name (Legal Business Name): GABRIELLE BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4071 E. 59TH ST.
CLEVELAND OH
44105
US

IV. Provider business mailing address

4071 E 59TH ST
CLEVELAND OH
44105-4815
US

V. Phone/Fax

Practice location:
  • Phone: 216-466-1676
  • Fax:
Mailing address:
  • Phone: 216-466-1676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2894748
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: