Provider Demographics
NPI:1730515222
Name:GUMBLE, DEBORA LYNN
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:LYNN
Last Name:GUMBLE
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 1:1955 US 1 S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3708
Mailing Address - Country:US
Mailing Address - Phone:904-825-5055
Mailing Address - Fax:904-825-6875
Practice Address - Street 1:1955 US 1 S
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3708
Practice Address - Country:US
Practice Address - Phone:904-825-5055
Practice Address - Fax:904-825-6875
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPPLIED FORMedicaid