MEDICARE: VANESSA GWYNN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1114568409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA GWYNN

Provider Business Mailing Address
First Line	:	4450 FAIRVIEW ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48214-1610
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4450 FAIRVIEW ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48214-1610
Country	:	US
Telephone Number	:	313-918-7619
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2019
Last Update Date	:	10/08/2019

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Directions to “ VANESSA GWYNN ” Practice Location

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