Provider Demographics
NPI:1366628661
Name:GAMBLE, TAMMY S
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:S
Last Name:GAMBLE
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:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-0172
Mailing Address - Country:US
Mailing Address - Phone:530-642-9774
Mailing Address - Fax:
Practice Address - Street 1:3265 SACRAMENTO STREET
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-0172
Practice Address - Country:US
Practice Address - Phone:530-642-1715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6890174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6890OtherCAS