Provider Demographics
NPI:1184200255
Name:MOORE, GAMBRELL
Entity Type:Individual
Prefix:
First Name:GAMBRELL
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4271 CYPRESS DR # 42
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-3406
Mailing Address - Country:US
Mailing Address - Phone:601-983-6016
Mailing Address - Fax:
Practice Address - Street 1:4271 CYPRESS DR # 42
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-3406
Practice Address - Country:US
Practice Address - Phone:601-983-6016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800753572374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS861625652Medicaid