Healthcare Provider Details

I. General information

NPI: 1255894333
Provider Name (Legal Business Name): LATEIA NATRIECE GAMBLE MCGEE HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LATEIA NATRIECE GAMBLE MCGEE HAIR LOSS SPECIALIST

II. Dates (important events)

Enumeration Date: 04/07/2019
Last Update Date: 04/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 POWDER SPRINGS RD SW STE 6
MARIETTA GA
30064-4847
US

IV. Provider business mailing address

2400 BARRETT CREEK BLVD APT 921
MARIETTA GA
30066-4965
US

V. Phone/Fax

Practice location:
  • Phone: 678-492-8671
  • Fax:
Mailing address:
  • Phone: 678-492-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO128967
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: