Provider Demographics
NPI:1972109247
Name:GAMBLE, DEREK PAUL (DNP, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:PAUL
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:KENNER ARMY HEALTH CLINIC, BUILDING 8130
Mailing Address - Street 2:700 24TH STREET
Mailing Address - City:FORT GREGG-ADAMS
Mailing Address - State:VA
Mailing Address - Zip Code:23801
Mailing Address - Country:US
Mailing Address - Phone:804-734-9145
Mailing Address - Fax:
Practice Address - Street 1:KENNER ARMY HEALTH CLINIC, BUILDING 8130
Practice Address - Street 2:700 24TH STREET
Practice Address - City:FORT GREGG-ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801
Practice Address - Country:US
Practice Address - Phone:804-734-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27944363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty