Healthcare Provider Details

I. General information

NPI: 1881634871
Provider Name (Legal Business Name): LISA F GAMBLE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 E AVALON AVE WING B
TUSCUMBIA AL
35674-1773
US

IV. Provider business mailing address

PO BOX 2587
MUSCLE SHOALS AL
35662-2587
US

V. Phone/Fax

Practice location:
  • Phone: 256-383-4473
  • Fax: 256-381-5232
Mailing address:
  • Phone: 256-383-4473
  • Fax: 256-381-5232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-092618
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: