Provider Demographics
NPI:1255894333
Name:GAMBLE MCGEE, LATEIA NATRIECE (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:LATEIA
Middle Name:NATRIECE
Last Name:GAMBLE MCGEE
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:LATEIA
Other - Middle Name:NATRIECE
Other - Last Name:GAMBLE MCGEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HAIR LOSS SPECIALIST
Mailing Address - Street 1:2400 BARRETT CREEK BLVD APT 921
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4965
Mailing Address - Country:US
Mailing Address - Phone:678-492-8671
Mailing Address - Fax:
Practice Address - Street 1:1651 POWDER SPRINGS RD SW STE 6
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4847
Practice Address - Country:US
Practice Address - Phone:678-492-8671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1289671744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACO128967OtherHAIR LOSS SPECIALIST