Provider Demographics
NPI:1417690439
Name:GAMBRILLS SISTERS HEALTH CARE
Entity Type:Organization
Organization Name:GAMBRILLS SISTERS HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FATU
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROMA
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:240-437-2705
Mailing Address - Street 1:106 CALUMET CT
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1060
Mailing Address - Country:US
Mailing Address - Phone:240-437-2705
Mailing Address - Fax:
Practice Address - Street 1:4710 PENNINGTON AVE
Practice Address - Street 2:
Practice Address - City:CURTIS BAY
Practice Address - State:MD
Practice Address - Zip Code:21226-1405
Practice Address - Country:US
Practice Address - Phone:240-437-2705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR187334OtherLICENSE