MEDICARE: GABRIELLE OLDHAM

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	163W00000X	Registered Nurse	RN 3358332	FL

General Provider Information

NPI Number	:	1093254195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE OLDHAM

Provider Business Mailing Address
First Line	:	6039 CYPRESS GARDENS BLVD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-4115
Country	:	US
Telephone Number	:	863-838-0685
Fax Number	:

Provider Business Practice Location Address
First Line	:	6039 CYPRESS GARDENS BLVD
Second Line	:	299
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-4115
Country	:	US
Telephone Number	:	863-838-0685
Fax Number	:

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

Provider Enumeration Date	:	02/22/2017
Last Update Date	:	02/22/2017

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