Basic Information
Provider Information
NPI: 1003003211
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GAMBLE
FirstName: ANTOINETTE
MiddleName: DENISE
NamePrefix:  
NameSuffix:  
Credential: N.P.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3156 MOUNT ZION RD APT 504
Address2:  
City: STOCKBRIDGE
State: GA
PostalCode: 302814182
CountryCode: US
TelephoneNumber: 9012191303
FaxNumber:  
Practice Location
Address1: 1670 CLAIRMONT RD.
Address2:  
City: DECATUR
State: GA
PostalCode: 300334098
CountryCode: US
TelephoneNumber: 4043216111
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/02/2007
LastUpdateDate: 10/02/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000XRN186234GAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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