Healthcare Provider Details

I. General information

NPI: 1629312566
Provider Name (Legal Business Name): LENA JEANELLE GAMBLE MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 05/20/2022
Certification Date: 02/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 BELCHER ST
CENTREVILLE AL
35042-2946
US

IV. Provider business mailing address

405 BELCHER ST
CENTREVILLE AL
35042-2946
US

V. Phone/Fax

Practice location:
  • Phone: 205-926-2992
  • Fax: 205-316-7675
Mailing address:
  • Phone: 205-926-2992
  • Fax: 205-316-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateDC
# 7
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.36062
License Number StateAL
# 10
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.36062
License Number StateAL
# 11
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: