Provider Demographics
NPI:1407507908
Name:GAMBRELL, WAYNE R
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:R
Last Name:GAMBRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 BERDAN AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-4610
Mailing Address - Country:US
Mailing Address - Phone:419-870-1189
Mailing Address - Fax:
Practice Address - Street 1:1738 BERDAN AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-4610
Practice Address - Country:US
Practice Address - Phone:419-870-1189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171613164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty