Provider Demographics
NPI:1417553736
Name:GAMBOL, AMELIA BROOKE (PRSS)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:BROOKE
Last Name:GAMBOL
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 PEAVEY CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5637
Mailing Address - Country:US
Mailing Address - Phone:580-372-3784
Mailing Address - Fax:833-402-9799
Practice Address - Street 1:300 N DALTON ST
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764-8029
Practice Address - Country:US
Practice Address - Phone:580-203-3600
Practice Address - Fax:833-402-9799
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist