Provider Demographics
NPI:1376904763
Name:GAMBOA, NATALY
Entity Type:Individual
Prefix:
First Name:NATALY
Middle Name:
Last Name:GAMBOA
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 1:1420 SW 84TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4147
Mailing Address - Country:US
Mailing Address - Phone:786-942-1322
Mailing Address - Fax:
Practice Address - Street 1:1420 SW 84TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4147
Practice Address - Country:US
Practice Address - Phone:786-942-1322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered