Healthcare Provider Details

I. General information

NPI: 1619961414
Provider Name (Legal Business Name): LAURA ELIZABETH GAMBLE MSN-CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA GAMBLE MCKENZIE

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 FARROW ROAD
COLUMBIA SC
29203
US

IV. Provider business mailing address

9 MEDICAL PARK SUITE 200-A
COLUMBIA SC
29203-8903
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-7950
  • Fax: 803-434-7981
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN 33555
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPN 2417
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2417
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: