Provider Demographics
NPI:1659843506
Name:GAMBLE, SHASTA LEE
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:LEE
Last Name:GAMBLE
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 1:1300 METRO EAST DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:IA
Mailing Address - Zip Code:50327-8906
Mailing Address - Country:US
Mailing Address - Phone:515-243-0011
Mailing Address - Fax:515-243-7711
Practice Address - Street 1:1300 METRO EAST DR STE 110
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:IA
Practice Address - Zip Code:50327-8906
Practice Address - Country:US
Practice Address - Phone:515-243-0011
Practice Address - Fax:515-243-7711
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider