Provider Demographics
NPI:1922612563
Name:GAMBRILL, TRACIE SHIRRELLE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:SHIRRELLE
Last Name:GAMBRILL
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 1:3029 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2751
Mailing Address - Country:US
Mailing Address - Phone:443-898-2180
Mailing Address - Fax:410-225-3230
Practice Address - Street 1:3029 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2751
Practice Address - Country:US
Practice Address - Phone:443-898-2180
Practice Address - Fax:410-225-3230
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30AL3873310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility