Healthcare Provider Details

I. General information

NPI: 1619776192
Provider Name (Legal Business Name): KRISTEN GAMBARDELLA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPROCESSING
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: