Basic Information
| Provider Information | |||||||||
| NPI: | 1003003211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAMBLE | ||||||||
| FirstName: | ANTOINETTE | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3156 MOUNT ZION RD APT 504 | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302814182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012191303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD. | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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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 | 363LF0000X | RN186234 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.