Basic Information
| Provider Information | |||||||||
| NPI: | 1750042453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAMBRELL | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | NYIEMA | ||||||||
| NamePrefix: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | GAMBRELL | ||||||||
| OtherFirstName: | BREANNA | ||||||||
| OtherMiddleName: | NYIEMA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 480 SAINT NICHOLAS AVE APT 3N | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100302753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6468954894 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 263 BLUE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | BLUE POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117151224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314196737 | ||||||||
| FaxNumber: | 6318683498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2022 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 340298 | NC | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | UT40202B | 05 | NY | MEDICAID |