Healthcare Provider Details

I. General information

NPI: 1417615089
Provider Name (Legal Business Name): TAMEKA YOLANDA GAMBLE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAMEKA YOLANDA MOSHER

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 HUTCHINSON AVE
SYRACUSE NY
13207-2118
US

IV. Provider business mailing address

117 HUTCHINSON AVE
SYRACUSE NY
13207-2118
US

V. Phone/Fax

Practice location:
  • Phone: 315-412-2599
  • Fax:
Mailing address:
  • Phone: 315-412-2599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number686790
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: