Healthcare Provider Details

I. General information

NPI: 1982399572
Provider Name (Legal Business Name): GABRIELE CLARK ORTIZ BA, COA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GABRIELE MARY CLARK BA, COA

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

733 LAUREL AVE
ALDAN PA
19018-4307
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-5800
  • Fax:
Mailing address:
  • Phone: 484-493-8244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: