Provider Demographics
NPI:1275252637
Name:GAMBLE, LISA DENITA (NURSE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DENITA
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 HERITAGE WALK
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3875
Mailing Address - Country:US
Mailing Address - Phone:678-494-5700
Mailing Address - Fax:
Practice Address - Street 1:270 HERITAGE WALK
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3875
Practice Address - Country:US
Practice Address - Phone:678-494-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN063961164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty