Healthcare Provider Details

I. General information

NPI: 1629201710
Provider Name (Legal Business Name): VICTORIA L GAMBLE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3644 W STATE HIGHWAY 18 STE B
MANILA AR
72442-8049
US

IV. Provider business mailing address

3644 W STATE HIGHWAY 18 STE B
MANILA AR
72442-8049
US

V. Phone/Fax

Practice location:
  • Phone: 870-561-3300
  • Fax: 870-561-3307
Mailing address:
  • Phone: 870-561-3300
  • Fax: 870-336-5321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003282
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: