Healthcare Provider Details

I. General information

NPI: 1629952411
Provider Name (Legal Business Name): GABRIELLE ELAINA GUTIERREZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 ROURK ST
MYRTLE BEACH SC
29572-4127
US

IV. Provider business mailing address

8120 ROURK ST
MYRTLE BEACH SC
29572-4127
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-1438
  • Fax:
Mailing address:
  • Phone: 843-449-1438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5955
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: