Healthcare Provider Details

I. General information

NPI: 1699894360
Provider Name (Legal Business Name): JILL A. GABRIELSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 PRAIRIE AVE
PROVIDENCE RI
02905
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0570
  • Fax: 401-444-0427
Mailing address:
  • Phone: 401-444-0400
  • Fax: 401-444-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number015709
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD15039
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: