Provider Demographics
NPI:1205254521
Name:GAMBOA, ROSE JENNIFER LUYUN
Entity type:Individual
Prefix:
First Name:ROSE JENNIFER
Middle Name:LUYUN
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 N. PINE ISLAND ROAD, APT 304
Mailing Address - Street 2:SHAMROCK APARTMENTS
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351
Mailing Address - Country:US
Mailing Address - Phone:703-627-8368
Mailing Address - Fax:
Practice Address - Street 1:1580 SAWGRASS CORPORATE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323
Practice Address - Country:US
Practice Address - Phone:954-739-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1237166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist