Provider Demographics
NPI:1801487780
Name:GAYLE, WIMBERLY REEVES
Entity type:Individual
Prefix:
First Name:WIMBERLY
Middle Name:REEVES
Last Name:GAYLE
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:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0266
Mailing Address - Country:US
Mailing Address - Phone:225-683-8195
Mailing Address - Fax:225-683-9826
Practice Address - Street 1:10463 PLANK RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3710
Practice Address - Country:US
Practice Address - Phone:225-683-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist