Basic Information
| Provider Information | |||||||||
| NPI: | 1164926267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE ALLIE | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2771 FARMSTEAD CT | ||||||||
| Address2: | |||||||||
| City: | GRAYSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300171511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3472958770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5000 KY ROUTE 321 STE 3141 | ||||||||
| Address2: | |||||||||
| City: | PRESTONSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416539113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068868511 | ||||||||
| FaxNumber: | 6068861316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2018 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 88990 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | GA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | TP707 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100816250 | 05 | KY | MEDICAID |