Basic Information
| Provider Information | |||||||||
| NPI: | 1316405145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHOLSTON | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | ELISHA | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4431 N CEDARWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996544406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049982394 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 670 W FIREWEED LN STE 160 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995032561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077700862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2019 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 128029 | AK | Y | Nursing Service Providers | Registered Nurse |
No ID Information.