Healthcare Provider Details

I. General information

NPI: 1629871470
Provider Name (Legal Business Name): GABRIELLE OLIVIA GONTAREK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 07/10/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-9166
  • Fax: 401-444-2788
Mailing address:
  • Phone: 401-793-9166
  • Fax: 401-444-2788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01797
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: