Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | RN186234 | GA |
NPI | 1003003211 |
---|---|
Provider Name | Antoinette Denise Gamble |
First Address | Stockbridge, GA 30281-4182 |
Second Address | Decatur, GA 30033-4098 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2007 |
Last Update Date | 02/10/2007 |