Healthcare Provider Details

I. General information

NPI: 1962191288
Provider Name (Legal Business Name): GAMBRILLS SISTERS HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 N 24TH AVE
PHOENIX AZ
85015-5947
US

IV. Provider business mailing address

106 CALUMET CT
GAMBRILLS MD
21054-1060
US

V. Phone/Fax

Practice location:
  • Phone: 240-437-2705
  • Fax:
Mailing address:
  • Phone: 240-437-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FATU N/A KOROMA
Title or Position: OWNER
Credential: DNP
Phone: 240-437-2705