MEDICARE: MRS. GWENDOLYN LALISA CUNNINGHAM

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1184081937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GWENDOLYN LALISA CUNNINGHAM

Provider Business Mailing Address
First Line	:	8020 MONCRIEF DINSMORE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32219-3602
Country	:	US
Telephone Number	:	904-627-6031
Fax Number	:

Provider Business Practice Location Address
First Line	:	3741 JACOB LOIS DR W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-2972
Country	:	US
Telephone Number	:	904-627-6031
Fax Number	:

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

Provider Enumeration Date	:	01/25/2016
Last Update Date	:	01/25/2016

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