Provider Demographics
NPI:1720788508
Name:GAMBOA, GERALDINE ALEJANDRO (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GERALDINE
Middle Name:ALEJANDRO
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:GERALDINE
Other - Middle Name:ALDANA
Other - Last Name:ALEJANDRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 BONNIE BRAE DR.
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-1701
Mailing Address - Country:US
Mailing Address - Phone:845-381-8311
Mailing Address - Fax:
Practice Address - Street 1:13 BONNIE BRAE DR.
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-1701
Practice Address - Country:US
Practice Address - Phone:845-381-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325303-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse