Basic Information
| Provider Information | |||||||||
| NPI: | 1699203406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COELHO | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM, ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEATON | ||||||||
| OtherFirstName: | GABRIELLE | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1818 COLE ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608025760 | ||||||||
| FaxNumber: | 3608025799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 COLE ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608025760 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0102X | RN60425446 | WA | N | Nursing Service Providers | Registered Nurse | Maternal Newborn | 367A00000X | AP60860350 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 2108511 | 05 | WA | MEDICAID |