Healthcare Provider Details

I. General information

NPI: 1679546329
Provider Name (Legal Business Name): GWENDOLYN WILSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 LOOP RD
TUSCALOOSA AL
35404-5015
US

IV. Provider business mailing address

3701 LOOP RD
TUSCALOOSA AL
35404-5015
US

V. Phone/Fax

Practice location:
  • Phone: 205-554-2000
  • Fax: 205-554-2869
Mailing address:
  • Phone: 205-554-2000
  • Fax: 205-554-2869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-048911
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: