Healthcare Provider Details

I. General information

NPI: 1407507908
Provider Name (Legal Business Name): MR. WAYNE R GAMBRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2022
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 BERDAN AVE
TOLEDO OH
43613-4610
US

IV. Provider business mailing address

1738 BERDAN AVE
TOLEDO OH
43613-4610
US

V. Phone/Fax

Practice location:
  • Phone: 419-870-1189
  • Fax:
Mailing address:
  • Phone: 419-870-1189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN.533016
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.171613.MED-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: