Provider Demographics
NPI:1184215618
Name:GAMBARDELLA, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GAMBARDELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14036 CARSON CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0868
Mailing Address - Country:US
Mailing Address - Phone:904-868-5146
Mailing Address - Fax:
Practice Address - Street 1:290 SOLANA RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2234
Practice Address - Country:US
Practice Address - Phone:904-543-8678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist