Provider Demographics
NPI:1740224401
Name:GAMBREL, CONNIE JO (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:JO
Last Name:GAMBREL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 S VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163
Mailing Address - Country:US
Mailing Address - Phone:317-861-5436
Mailing Address - Fax:317-861-5436
Practice Address - Street 1:3924 S VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163
Practice Address - Country:US
Practice Address - Phone:317-861-5436
Practice Address - Fax:317-861-5436
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28066452A163WP0808X
IN70000110A163WP0807X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100323760AMedicaid