Provider Demographics
NPI:1801054432
Name:GAMBACORTA, OLIMPIA (LPN)
Entity type:Individual
Prefix:MRS
First Name:OLIMPIA
Middle Name:
Last Name:GAMBACORTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FREEDOM RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2531
Mailing Address - Country:US
Mailing Address - Phone:914-328-3157
Mailing Address - Fax:
Practice Address - Street 1:16 FREEDOM RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-2531
Practice Address - Country:US
Practice Address - Phone:914-328-3157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2375411164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02043814Medicaid