1164962585 NPI number — GABRIELLA ELENORA LOFTON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164962585 NPI number — GABRIELLA ELENORA LOFTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOFTON
Provider First Name:
GABRIELLA
Provider Middle Name:
ELENORA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SEIDA
Provider Other First Name:
GABRIELLA
Provider Other Middle Name:
ELENORA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164962585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4225 SOUTHPORT CIR APT 3C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKEMOS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48864-2807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-230-4915
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9080 W MAPLE RAPIDS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOWLER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48835-9605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-230-4915
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X , with the licence number:  S 300 271 205 932 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)