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General NPI Number Information
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NPI Number | 1023498060
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Entity Type | Individual
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Provider Name | TRACEY ASHLEY GILL
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Gender | Female
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Dates
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Enumeration Date | 06/04/2015
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Last Update Date | 06/04/2015
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Provider Practice Location Address
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Address Line | 235 BLUE POINT AVE #A
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City | BLUE POINT
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State | NY
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Zip | 11715-1261
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Country | US
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Telephone | 631-363-5794
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Fax |
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Provider Business Mailing Address
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Address Line | 584 MIDDLE ROAD EAST APARTMENT
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City | BAYPORT
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State | NY
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Zip | 11705
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Country | US
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Telephone | 631-805-7616
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 528541111
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License Number State | NY
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