Healthcare Provider Details

I. General information

NPI: 1376119628
Provider Name (Legal Business Name): AMBER ROSE GAMBLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 US HIGHWAY 23 S
ALPENA MI
49707-4542
US

IV. Provider business mailing address

490 PINE MEADOW LN APT 53
ALPENA MI
49707-1382
US

V. Phone/Fax

Practice location:
  • Phone: 989-354-4630
  • Fax: 989-354-0030
Mailing address:
  • Phone: 727-485-6888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303023960
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: