MEDICARE: GABRIELLE MEDIANO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	13260579-4701	UT

General Provider Information

NPI Number	:	1073206074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE MEDIANO

Provider Business Mailing Address
First Line	:	5057 W EAGLE ROCK WAY
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-1423
Country	:	US
Telephone Number	:	801-634-4904
Fax Number	:

Provider Business Practice Location Address
First Line	:	5057 W EAGLE ROCK WAY
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-1423
Country	:	US
Telephone Number	:	801-634-4904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2023
Last Update Date	:	05/26/2023

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Directions to “ GABRIELLE MEDIANO ” Practice Location

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