=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881560829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIELLE MIRE BLACK PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2025
-----------------------------------------------------
Last Update Date | 10/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4402 U S HIGHWAY 167
-----------------------------------------------------
City | MAURICE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70555-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-516-3110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3420 KIRK RD
-----------------------------------------------------
City | MAURICE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70555-3417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 348969
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------