Healthcare Provider Details

I. General information

NPI: 1538138193
Provider Name (Legal Business Name): DOROTHY R GAMBLE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2832 N 58TH ST
MILWAUKEE WI
53210-1541
US

IV. Provider business mailing address

2832 N 58TH ST
MILWAUKEE WI
53210-1541
US

V. Phone/Fax

Practice location:
  • Phone: 414-873-0141
  • Fax:
Mailing address:
  • Phone: 414-873-0141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number32386-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: