Provider Demographics
NPI:1457436008
Name:GAMBILL, STACY JOHNSON (FNP)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:JOHNSON
Last Name:GAMBILL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-0208
Mailing Address - Country:US
Mailing Address - Phone:336-246-9449
Mailing Address - Fax:336-982-3555
Practice Address - Street 1:413 MCCONNELL ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9772
Practice Address - Country:US
Practice Address - Phone:336-246-9449
Practice Address - Fax:336-846-2025
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167387363LF0000X
NC5000711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV9055B667OtherPTAN