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NPI Code Detail

MEDICARE: DR. GWEN LATENDRESSE CNM, PHD

MEDICARE: DR. GWEN LATENDRESSE CNM, PHD
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
1367A00000XAdvanced Practice Midwife95-216631-4402UT

General Provider Information

NPI Number : 1629226808
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. GWEN LATENDRESSE CNM, PHD
Provider Business Mailing Address
First Line : 10 S 2000 E
Second Line : ROOM 448
City : SALT LAKE CITY
State : UT
Zip : 84112-5880
Country : US
Telephone Number : 801-587-9636
Fax Number : 801-587-9838
Provider Business Practice Location Address
First Line : 10 S 2000 E
Second Line : ROOM 448
City : SALT LAKE CITY
State : UT
Zip : 84112-5880
Country : US
Telephone Number : 801-587-9636
Fax Number : 801-587-9838
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/30/2008
Last Update Date : 08/30/2008

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