Provider Demographics
NPI:1053943431
Name:GABLE, TAMMY SUE
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:SUE
Last Name:GABLE
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 1:733 PARK LN
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-1262
Mailing Address - Country:US
Mailing Address - Phone:937-508-0428
Mailing Address - Fax:
Practice Address - Street 1:927 W COURT ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-1927
Practice Address - Country:US
Practice Address - Phone:937-508-0428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0274353374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1102813Medicaid
OH0274353Medicaid