Provider Demographics
NPI:1750042453
Name:GAMBRELL, BREANNA NYIEMA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:NYIEMA
Last Name:GAMBRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BREANNA
Other - Middle Name:NYIEMA
Other - Last Name:GAMBRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:480 SAINT NICHOLAS AVE APT 3N
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2753
Mailing Address - Country:US
Mailing Address - Phone:646-895-4894
Mailing Address - Fax:
Practice Address - Street 1:263 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1224
Practice Address - Country:US
Practice Address - Phone:631-419-6737
Practice Address - Fax:631-868-3498
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC340298163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYUT40202BMedicaid